2025 CPT code 21365
(Active) Effective Date: N/A Revision Date: N/A Surgery - Fracture and Dislocation Treatment Musculoskeletal System Feed
Open treatment of complicated malar fracture with internal fixation and multiple surgical approaches.
Modifiers may be applicable depending on the circumstances of the surgical procedure.For instance, modifier 51 (multiple procedures), 59 (distinct procedural service), or 76 (repeat procedure) could be used in certain situations.Consult the CPT guidelines for appropriate modifier use.
Medical necessity is established by the presence of a symptomatic and unstable malar fracture requiring surgical intervention to restore facial structure and function.The complexity of the fracture, as demonstrated by imaging and clinical examination, justifies the use of open reduction and internal fixation with multiple approaches.
The clinical responsibility involves pre-operative assessment, surgical planning, meticulous surgical technique to ensure proper bone alignment and fixation, post-operative monitoring for complications (e.g., infection, nerve injury), and patient education regarding recovery and follow-up care.This requires a high level of surgical skill and judgment.
In simple words: This code covers a complex surgery to fix a broken cheekbone.The break is severe, possibly shattered or near important nerves. The surgeon makes several incisions, puts in plates or wires to hold the bone together, and then closes the incisions.
This CPT code, 21365, encompasses the open surgical treatment of complex fractures in the malar region, including the zygomatic arch and malar tripod.The complexity may involve comminution (fracture into multiple pieces) or proximity to cranial nerve foramina. The procedure includes internal fixation (e.g., plates, wires) and necessitates multiple surgical approaches for optimal access and repair.Preoperative planning, meticulous dissection to expose the fracture site, precise reduction (realignment) of bone fragments, secure fixation, irrigation, hemostasis (control of bleeding), and layered closure are integral components.
Example 1: A patient presents after a motor vehicle accident with a severely comminuted zygomatic fracture involving the zygomatic arch and malar tripod.The fracture requires open reduction and internal fixation using multiple surgical approaches to achieve anatomic realignment and stable fixation., A patient sustains a complex malar fracture during a sporting event, resulting in displacement of the zygomatic bone and involvement of the infraorbital nerve.Open reduction and internal fixation are performed through multiple approaches, with meticulous attention paid to nerve preservation and restoration of facial contour., A patient undergoes open reduction and internal fixation of a malar fracture secondary to assault.Multiple approaches are required to address the comminuted fracture and the disruption of the malar tripod.The surgeon carefully addresses the fracture fragments and utilizes internal fixation for stabilization.
* Thorough history and physical examination documenting the mechanism of injury and the extent of the fracture.* Preoperative imaging (e.g., CT scan) to delineate the fracture pattern and plan the surgical approach.* Operative report detailing the surgical techniques used, including the number and type of approaches, type of fixation, and intraoperative findings (e.g., nerve involvement).* Postoperative imaging to confirm fracture reduction and fixation stability.* Documentation of post-operative course, including any complications and the patient's response to treatment.
** Accurate coding requires a comprehensive understanding of the fracture's complexity, the surgical approach, and the internal fixation techniques used.Documentation should be clear, concise, and support the medical necessity of the procedure.
- Revenue Code: P5B (Ambulatory Procedures - Musculoskeletal)
- RVU: The relative value units (RVUs) for CPT code 21365 vary based on geographic location, facility type, and other factors.Consult a current fee schedule for precise values.RVUs reflect the resources and work involved in the procedure.
- Global Days: The global period for this procedure will vary according to payer and local custom. The global period encompasses the pre-operative, intra-operative, and post-operative care.Consult payer guidelines for specific details.
- Payment Status: Active
- Modifier TC rule: Modifier TC (technical component) is not typically applicable to this code as it represents the entire surgical procedure.
- Fee Schedule: Historical fee schedules for CPT code 21365 will vary based on payer and location.Consult historical fee data for the relevant period to obtain the information.
- Specialties:Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Ambulatory Surgical Center, Hospital (Inpatient and Outpatient), Office-based Surgery Center