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The procedure described by CPT® Code 21360 involves the open treatment of a depressed malar fracture, which specifically includes the zygomatic arch and the malar tripod. A malar fracture refers to a break in the cheekbone area, which can lead to cosmetic and functional issues if not properly addressed. In this procedure, the physician performs the treatment in an open surgical environment, meaning that the area is directly accessed through incisions rather than through minimally invasive techniques. Notably, this procedure does not utilize internal fixation methods, which are often used in other types of fracture repairs. Instead, the physician creates incisions around the facial area, including an intraoral incision through the maxillary buccal vestibule, allowing for direct access to the fractured bones. The reduction of the fracture, which is the process of realigning the broken bone to its normal anatomical position, is achieved using instruments such as the Carroll-Girard screw, which assists in lifting the fractured bones back into place. Additionally, manual reduction techniques are employed on the malar complex to ensure proper alignment. After the fracture has been successfully reduced, all incisions made during the procedure are meticulously closed to promote healing and minimize scarring.
© Copyright 2025 Coding Ahead. All rights reserved.
The open treatment of a depressed malar fracture, as described by CPT® Code 21360, is indicated for specific conditions and symptoms associated with facial trauma. The following are the primary indications for this procedure:
The procedure for the open treatment of a depressed malar fracture involves several critical steps to ensure proper alignment and healing of the fractured bones. The following outlines the procedural steps:
Post-procedure care following the open treatment of a depressed malar fracture is critical for recovery. Patients are typically monitored for any signs of complications, such as infection or improper healing. Pain management may be provided as needed, and patients are advised on activity restrictions to avoid undue stress on the healing facial structures. Follow-up appointments are essential to assess the healing process and ensure that the fracture remains properly aligned. Additionally, patients may receive instructions on oral care, especially if intraoral incisions were made, to promote healing and prevent infection.
| Short Descr | OPN TX DPRSD MALAR FRACTURE | Medium Descr | OPEN TX DEPRESSED MALAR FRACTURE | Long Descr | Open treatment of depressed malar fracture, including zygomatic arch and malar tripod | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 2 - Payment restriction for assistants at surgery does not apply 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 | Non office-based surgical procedure added in CY 2008 or later; 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 |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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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