2025 CPT code 21356
(Active) Effective Date: N/A Revision Date: N/A Surgery - Fracture and/or Dislocation Procedures on the Head Musculoskeletal System Feed
Open treatment of a depressed zygomatic arch fracture.
Modifiers 50 (bilateral procedure), 51 (multiple procedures), 52 (reduced services), 76 (repeat procedure), and others as clinically indicated, may be applicable depending on the circumstances of the surgical procedure.
Medical necessity for open reduction of a zygomatic arch fracture is established when conservative management is unsuccessful or when the fracture causes significant functional impairment (e.g., malocclusion, visual impairment), cosmetic deformity, or risk of complications.Documentation must clearly demonstrate the need for surgical intervention.
The physician is responsible for pre-operative assessment, surgical planning and execution, including incision, fracture reduction, irrigation, hemostasis (control of bleeding), and wound closure. Post-operative care may be included in the global surgical package depending on payer rules.
In simple words: The doctor surgically repairs a broken cheekbone that's been pushed inward.This involves making an incision, fixing the bone, cleaning the area, and closing the cut.
Open treatment of a depressed zygomatic arch fracture, such as using the Gillies approach, involves a surgical incision to access and repair the fracture.The procedure includes accessing the fracture, reducing (realigning) the fractured bone segments, irrigating the area, controlling bleeding, and closing the incision.The Gillies approach specifically uses an incision behind the hairline for access.
Example 1: A patient presents after a motor vehicle accident with a depressed zygomatic arch fracture.The physician performs an open reduction and internal fixation (ORIF) via a Gillies approach., A patient sustains a depressed zygomatic fracture during a sporting event. The physician performs open reduction and internal fixation using a Gillies approach, followed by postoperative care., A patient with a complex zygomatic fracture requiring bone grafting undergoes open reduction and internal fixation via a Gillies approach. Bone graft is coded separately.
* Preoperative diagnosis (including imaging studies like CT scans) clearly indicating a depressed zygomatic arch fracture.* Operative report detailing the surgical approach (e.g., Gillies approach), steps undertaken, and materials used.* Intraoperative imaging (if used) to confirm fracture reduction.* Postoperative instructions and follow-up plan.
** This code is used for open treatment of depressed zygomatic arch fractures.Other approaches besides the Gillies approach may be used and appropriately coded.If additional procedures are performed (e.g., bone grafting, nerve repair), these should be reported with separate codes.
- Revenue Code: P3D (Major Procedure, Orthopedic - Other)
- Payment Status: Active
- Fee Schedule: Unknown
- Specialties:Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital