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The procedure described by CPT® Code 21366 involves the open treatment of complicated fractures in the malar area, which includes the zygomatic arch and malar tripod. These types of fractures are characterized as complicated due to their nature, which may include comminuted fractures or those that affect cranial nerve foramina. In this surgical intervention, the physician employs an open approach to access the fracture site, allowing for direct visualization and manipulation of the fractured bones. The use of multiple surgical techniques, such as a transoral incision through the maxillary buccal vestibule, facilitates access to the affected area. Once the fracture is accessed, the physician carefully reduces the fracture to its correct anatomical position, often utilizing specialized instruments like the Carroll-Girard screw to lift and align the fractured segments. Additionally, the procedure includes obtaining a bone graft from the patient’s own body, which may be harvested from areas such as the hip, rib, or skull. This graft is then placed into the defect areas to promote healing and stability. To ensure proper alignment and support of the fractured bones, the physician employs screws, wires, and/or plates for stabilization. Finally, all incisions made during the procedure are meticulously closed to promote optimal healing and recovery.
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The open treatment of complicated fractures of the malar area, as described by CPT® Code 21366, is indicated for specific conditions that necessitate surgical intervention. These indications include:
The procedure for the open treatment of complicated fractures of the malar area involves several critical steps to ensure effective repair and stabilization of the fracture site. Each step is essential for achieving optimal outcomes.
Post-procedure care following the open treatment of complicated fractures of the malar area includes monitoring for any signs of complications, such as infection or improper healing. Patients are typically advised on pain management strategies and may be prescribed medications to aid in recovery. Follow-up appointments are essential to assess the healing process and ensure that the fracture remains stable. Rehabilitation may also be recommended to restore function and mobility in the affected area, depending on the extent of the injury and the surgical intervention performed.
| Short Descr | OPN TX COMPLX MALAR W/GRFT | Medium Descr | OPEN TX COMP FRACTURE MALAR AREA W/BONE GRAFT | Long Descr | Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft) | 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) | 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met. | 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
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