Open treatment of a depressed malar (cheekbone) fracture involving surgical reduction and fixation of the fractured zygoma or zygomatic arch.

Verified May 8, 2026 · 6 sources ↓

Medicare: $468.61
Work RVU: 7.01
Global, days: 90
Region: Other

Drawn from CMSCgsmedicareAAOS

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Operative note must name the surgical approach (e.g., coronal, subciliary, transconjunctival, intraoral gingivobuccal) — 'standard approach' is an audit flag.
Describe the degree of malar depression and clinical or radiographic evidence (CT imaging preferred) confirming the fracture pattern and displacement.
Document intraoperative confirmation of reduction, including how reduction was assessed (direct visualization, tactile symmetry, intraoperative imaging).
Identify fixation method and hardware used (miniplate size, screw count, and placement sites) to support the complexity of the procedure.
If modifier 22 is appended, include a separate attestation in the operative note explaining what made the work substantially greater than typical for 21360.
Record preoperative diagnosis with ICD-10 specificity — laterality and fracture pattern must match the procedure 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 57 Decision for surgery 58 Staged or related 59 Distinct service 62 Co-surgeons 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21360 covers open surgical treatment of a depressed malar fracture — the zygoma or zygomatic complex — where the fracture requires direct exposure and reduction rather than closed or percutaneous techniques. The surgeon accesses the fracture site through an incision (commonly coronal, subciliary, transconjunctival, or intraoral), reduces the depressed segment, and stabilizes it with rigid fixation such as miniplates and screws. The 90-day global period applies, meaning all routine postoperative care through day 90 is bundled into the payment.

Documentation must clearly distinguish this from 21355 (percutaneous treatment) and 21365 (complex or comminuted malar fracture requiring bone grafting or more extensive fixation). The operative note must describe the approach used, the degree of depression, how reduction was confirmed (typically intraoperatively and/or with imaging), and the fixation method and hardware. Vague notes referencing only 'open reduction of facial fracture' invite downcoding or audit requests.

If a same-day E/M visit generated the decision for surgery, append modifier 57 to the E/M code — 21360 carries a 90-day global, so the day-of or day-before decision visit qualifies. Unrelated procedures performed in the same operative session require modifier 79. If the complexity of the reduction substantially exceeds the typical work — e.g., severe comminution that still doesn't meet 21365 criteria, or an unusually scarred or previously operated field — modifier 22 is defensible with supporting documentation.

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 (7.01) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (14.03) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	7.01
Practice expense RVU	5.98
Malpractice RVU	1.04
Total RVU	14.03
Medicare national rate	$468.61
Global period	90 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	$468.61
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI G2) Ambulatory surgical center (freestanding)	$3,025.62

Common denial reasons

The recurring reasons claims for CPT 21360 get rejected.

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

Operative note fails to document the surgical approach by name, triggering a request for records or downcoding to a lesser fracture repair code.
Code billed as 21365 (complex malar fracture) when documentation only supports 21360 level of complexity — or vice versa, undercoding when complexity is actually higher.
Missing laterality modifier (LT or RT) when payer policy requires it for unilateral facial procedures, resulting in claim suspension.
E/M visit billed same day without modifier 57, causing denial of the office visit as bundled into the 90-day global surgical package.
Unrelated procedure performed in the global period submitted without modifier 79, causing automatic bundling denial by the payer.
Preoperative CT or imaging not documented in the record, leaving medical necessity for open (versus closed) treatment unsupported.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What distinguishes CPT 21360 from 21355 and 21365?

21355 is percutaneous or indirect treatment of a depressed malar fracture — no formal open incision. 21360 requires open exposure and direct reduction. 21365 is reserved for complex or comminuted malar fractures that involve more extensive reconstruction, often including bone grafting. If your operative note describes direct open reduction with rigid fixation but no grafting and no severe comminution, 21360 is the correct code.

02Does the 90-day global period apply to CPT 21360?

Yes. The 90-day global covers the surgery, the day-before visit, and all routine postoperative care through day 90. Any E/M visit unrelated to the fracture repair during that window needs modifier 24. The decision-for-surgery visit on the day of or day before the procedure needs modifier 57.

03When is modifier 22 appropriate for 21360?

Append modifier 22 when the operative work is substantially greater than typical — for example, a previously operated field with significant scarring, severe comminution that does not rise to 21365 criteria, or unusually difficult reduction. The operative note must contain a specific written statement explaining what increased the work. Without that documentation, payers will strip the modifier and reprocess at the base rate.

04Should laterality modifiers LT or RT be used with 21360?

Many commercial payers and some MACs require LT or RT on unilateral facial fracture repairs. Check your payer's specific policy. Omitting laterality when required suspends the claim. It does not affect Medicare payment rate but does affect processing speed and can trigger a request for records.

05Can 21360 and a same-day nasal fracture repair be billed together?

Potentially yes, with modifier 51 appended to the secondary procedure. Check NCCI PTP edits for the specific code pairing first using the CMS NCCI lookup tool — some facial fracture repair combinations have modifier indicator 0 (not bypassable). If the edit allows a modifier and both procedures are clinically distinct and documented, modifier 51 or 59/XS may apply depending on the edit.

06What ICD-10 codes typically pair with CPT 21360?

The primary ICD-10 codes are in the S02.4 category (fractures of malar, maxillary, and orbital bones). Specificity matters — code to laterality and fracture type (displaced vs. nondisplaced). A mismatch between the ICD-10 displacement type and the operative note description of a depressed fracture will draw scrutiny on audit.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the surgical approach by name, degree of malar depression, intraoperative reduction confirmation method, and fixation hardware details directly from dictation. This prevents the two most common audit flags for 21360: operative notes that omit the approach name and notes that lack fixation specifics — both of which prompt downcoding or record requests from payers.

See how Mira captures CPT 21360 documentation