2025 CPT code 21360
(Active) Effective Date: N/A Revision Date: N/A Surgery - Fracture and/or Dislocation Treatment Musculoskeletal System Feed
Open treatment of a depressed malar fracture, involving the zygomatic arch and malar tripod.
Modifiers may be applicable in certain situations such as multiple procedures (modifier 51), bilateral procedures (modifier 50), or when a portion of the service is discontinued (modifiers 53, 73, 74).Consult CPT and NCCI guidelines for appropriate modifier use.
Medical necessity is established by the presence of a symptomatic depressed malar fracture that is causing significant functional impairment, esthetic deformity, or risk of complications. The need for open surgical intervention should be clearly documented.
The clinical responsibility rests with the surgeon performing the open reduction and repair of the malar fracture. This includes pre-operative assessment, surgical planning, execution of the surgical procedure, post-operative care, and follow-up.Anesthesiologists, nurses, and other surgical staff also have defined roles in the procedure.
In simple words: The doctor surgically repairs a broken cheekbone (malar fracture). This involves an incision to access the broken parts, realigning them, and closing the cut. Special tools may be used to help put the bone back into place.
This CPT code encompasses the open surgical treatment of a depressed malar fracture, specifically addressing the zygomatic arch and malar tripod.The procedure involves a surgical incision to access the fracture site, reduction (realignment) of the fractured bone segments, and closure of the incision.It may include the use of instruments to aid in the reduction process. Internal fixation may or may not be used, depending on the specifics of the fracture.
Example 1: A patient presents with a depressed zygomatic fracture following a motor vehicle accident.Open reduction and internal fixation is performed using 21360., A patient sustains a complex malar fracture with displacement and comminution. Open reduction with multiple approaches and internal fixation is performed using 21360., A patient suffers a zygomatic fracture requiring open reduction.The surgeon chooses not to use internal fixation.21360 remains the appropriate code.
Detailed operative notes describing the surgical approach, techniques employed (including instrument use), and the extent of the fracture repair. Pre-operative imaging (e.g., CT scans) and post-operative imaging to confirm fracture reduction.All relevant clinical findings and assessment notes must be included in the medical record.
** Thorough documentation is crucial for accurate coding and reimbursement.Ambiguity in documentation can lead to claim denials.Always ensure that the documentation supports the medical necessity of the procedure and aligns with the code description.
- Payment Status: Active
- Modifier TC rule: Not applicable for this procedure code.The TC (Technical Component) modifier relates to anesthesia services.
- Specialties:Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Office-based Surgery