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The CPT® Code 21355 refers to the percutaneous treatment of fractures in the malar area, which encompasses the zygomatic arch and the malar tripod. This procedure is specifically designed for cases where there is a fracture in these facial structures, which are critical for maintaining the integrity of the facial skeleton and aesthetics. The term "percutaneous" indicates that the treatment is performed through the skin, minimizing the need for larger incisions and reducing recovery time. During the procedure, the physician creates a small stab wound in the cheek area, allowing access to the fractured bone. Using specialized instruments such as a rod or bone hook, the physician carefully manipulates the fractured segments back into their proper alignment. Once the bone is repositioned, the instrument is withdrawn, and the small incision is closed, typically with sutures or adhesive strips. This method is advantageous as it often results in less trauma to the surrounding tissues, reduced pain, and quicker healing compared to more invasive surgical techniques.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21355 is indicated for the treatment of fractures in the malar area, specifically involving the zygomatic arch and malar tripod. These fractures may occur due to various traumatic events, such as falls, sports injuries, or vehicular accidents. The primary indications for performing this procedure include:
The procedure for CPT® Code 21355 involves several critical steps to ensure effective treatment of the malar area fracture. The steps are as follows:
After the completion of the procedure, the patient is monitored for any immediate complications. Post-procedure care typically includes instructions for pain management, which may involve prescribed analgesics. The patient may also be advised to avoid strenuous activities and to follow up with their healthcare provider for further evaluation and monitoring of the healing process. It is essential to observe for any signs of infection or complications at the incision site. The expected recovery time can vary based on the extent of the fracture and the individual’s overall health, but patients generally experience a quicker recovery due to the minimally invasive nature of the procedure.
| Short Descr | PERQ TX MALAR FRACTURE | Medium Descr | PERCUTANEOUS TX MALAR AREA FRACTURE | Long Descr | Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 144 - Treatment, facial fracture or dislocation |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| Pre-1990 | Added | Code added. |
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