Percutaneous treatment of a malar (cheekbone) fracture using manipulation through puncture incisions, without open exposure of the fracture site.

Verified May 8, 2026 · 5 sources ↓

Medicare: $445.57
Work RVU: 4.34
Global, days: 10
Region: Other

Drawn from CMSAAPCFastrvuAskphcIowaprotocols

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 5 cited references ↓

Operative note must explicitly name the percutaneous technique — describe the puncture incision location(s) and instrument used for manipulation.
Confirm no hardware or internal fixation was placed; if plates or screws were used, a higher-level open reduction code applies.
Document pre- and post-reduction assessment of fracture position, ideally with imaging correlation (CT or fluoroscopy findings).
Record mechanism of injury and laterality (left vs. right zygoma) to support ICD-10 code selection and modifier application.
Note any concurrent facial fractures treated in the same session and document each as a separate anatomic injury if billing additional codes.
Identify the operating surgeon and confirm who will provide post-operative follow-up; use modifier 54 if surgical care only is being billed.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 21355 describes percutaneous reduction of a malar fracture — the cheekbone (zygoma) is manipulated back into alignment through small puncture incisions rather than an open surgical approach. The technique avoids formal dissection and direct visualization of the fracture, distinguishing it from open reduction codes such as 21356 and 21366. It carries a 10-day global period, meaning routine follow-up through postoperative day 10 is included in the payment.

This code sits between closed treatment without manipulation (an E/M-level service) and fully open reduction with internal fixation. If your operative note describes any plate fixation or hardware placement, 21355 is not the right code — route those cases to the open reduction family. Percutaneous does not mean 'minimally invasive with hardware'; it means the fracture was reduced through puncture access without direct exposure.

Malar fractures frequently occur alongside other facial fractures, particularly zygomaticomaxillary complex (ZMC or tripod) injuries. When multiple facial fractures are treated in the same operative session, each anatomically distinct fracture may be separately reportable — append modifier 51 and verify NCCI edits before billing additional facial fracture codes on the same date.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (4.34) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (13.34) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	4.34
Practice expense RVU	8.38
Malpractice RVU	0.62
Total RVU	13.34
Medicare national rate	$445.57
Global period	10 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$445.57
HOPD (APC 5164) Hospital outpatient department	$3,387.27
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,480.50

Common denial reasons

The recurring reasons claims for CPT 21355 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Operative note describes open exposure or hardware placement, making 21355 a mismatch — payers downcode or deny when documentation supports a higher open reduction code.
Missing laterality in the diagnosis code causes claim rejection; ICD-10 malar fracture codes require left, right, or unspecified specification.
Billing 21355 alongside other facial fracture reduction codes without modifier 51 or without verifying NCCI bundling triggers an NCCI edit denial.
Insufficient documentation of percutaneous technique — notes that only say 'fracture reduced' without describing the puncture approach are flagged as lacking specificity.
Prior authorization not obtained when required by the payer for facial fracture surgical procedures, particularly for elective or delayed repair.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01How does 21355 differ from 21356 and the other open malar fracture codes?

21355 is percutaneous — reduction through puncture incisions with no open exposure. Codes 21356 and above involve direct surgical exposure of the fracture site, with or without internal fixation. If your note describes an incision for visualization or any hardware placement, you're past 21355.

02What global period applies, and what's included?

21355 carries a 10-day global period. That covers the surgery and all routine follow-up visits through postoperative day 10. An unrelated E/M during that window needs modifier 24; a related E/M on the same day as surgery needs modifier 24 or 57 depending on whether the decision for surgery occurred then.

03Can I bill 21355 with other facial fracture codes on the same date?

Potentially yes, if anatomically distinct fractures were each treated. Append modifier 51 to the secondary procedure code and verify NCCI edits first. Don't assume all facial fracture codes are separately billable — check each pair.

04When should modifier 54 be used with 21355?

Use modifier 54 when the operating surgeon is providing surgical care only and a different provider will handle the post-operative follow-up. The treating provider bills 21355-54; the follow-up provider bills 21355-55 for the post-op management portion.

05Does 21355 require prior authorization?

It depends on the payer. Many commercial plans require prior authorization for facial fracture surgery, even percutaneous approaches. Medicaid managed care plans vary by state. Verify with the specific payer before scheduling non-emergent cases.

06Is modifier 22 defensible for a particularly complex malar reduction?

Yes, if the procedure required substantially more work than typical — for example, a significantly displaced or comminuted fracture requiring extended manipulation or multiple reduction attempts. Document the specific factors that increased complexity in the operative note; a brief cover letter explaining the increased work strengthens the claim.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira Scribe

Mira's AI scribe captures the percutaneous technique from dictation — puncture incision location, manipulation instrument, intraoperative imaging confirmation, and absence of internal fixation — and flags the note if open exposure language appears, preventing miscoding between 21355 and the open reduction codes. It also captures laterality and concurrent facial fractures so ICD-10 specificity and modifier 51 opportunities aren't missed at charge entry.

See how Mira captures CPT 21355 documentation