Open surgical repair of a complicated malar (cheekbone) fracture, including comminuted patterns or fractures involving cranial nerve foramina, using multiple approaches as needed.

Verified May 8, 2026 · 7 sources ↓

Medicare: $962.61
Total RVUs: 28.82
Global, days: 90
Region: Other

Drawn from CMSAAPCFindacodeCgsmedicare

Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Specify fracture complexity: document comminution, cranial nerve foramina involvement, or other complicating features that distinguish this from a simple malar fracture
Name every surgical approach used (e.g., subciliary, transconjunctival, hemicoronal, gingivobuccal sulcus) — 'standard approach' is an audit red flag
Preoperative imaging (CT of facial bones) confirming fracture pattern and complexity must be referenced or attached
Intraoperative findings documented with fracture fragment count, displacement, and any nerve involvement observed
Fixation method and hardware specifics (plate size, screw count, material) if internal fixation was applied
If co-surgeons billed: each surgeon's operative note must describe their distinct, non-overlapping contribution

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 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 21365 covers open treatment of a complicated malar area fracture — one that is comminuted, involves cranial nerve foramina, or otherwise requires more extensive surgical management than a straightforward malar or zygomatic arch repair. The zygomatic arch and malar tripod are included in the operative field. 'Multiple approaches' is the defining feature that separates this code from simpler open malar repairs (21360, 21356); if a single approach was used and the fracture was not comminuted or foramina-involving, a lower-intensity code applies.

This carries a 90-day global period. All routine postoperative visits, wound checks, and hardware assessments through day 90 are bundled. New problems or complications unrelated to the original fracture repair require modifier 79; an unplanned return to the OR for a related complication requires modifier 78. An evaluation and management service on the day of surgery for a separately identifiable decision-to-operate visit requires modifier 57 when billed with this 090-global code.

21365 has a terminated device procedure designation per CMS transmittal history, meaning when the procedure is terminated early, a device credit amount applies. Co-surgeon billing (modifier 62) is supported when two surgeons with different skill sets each perform a distinct portion — document each surgeon's role explicitly in separate operative notes.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	16.35
Practice expense RVU	9.88
Malpractice RVU	2.59
Total RVU	28.82
Medicare national rate	$962.61
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	$962.61
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 21365 get rejected.

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

Downcoded to 21360 or 21356 when operative note fails to document comminution or foramina involvement — complexity must be explicit, not implied
Unbundling denied when orbitotomy (e.g., 67450) is billed same-day without documentation that the orbital procedure was distinct and not integral to the malar repair
Co-surgeon modifier 62 denied when both operative notes describe identical work rather than separate, distinct surgical roles
Global period violation: postoperative E/M visits billed without modifier 24 during the 90-day global window
Modifier 57 missing on the same-day E/M that drove the decision to perform this 090-global surgery

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What separates 21365 from 21360?

21360 covers open treatment of a depressed malar fracture via a single approach without comminution or foramina involvement. 21365 is for complicated fractures — comminuted patterns, cranial nerve foramina involvement, or cases requiring multiple surgical approaches. The complexity must be documented explicitly in the operative note.

02Can I bill 67450 (orbitotomy) with 21365 on the same day?

Only if the orbitotomy was a distinct procedure not integral to the malar repair. AAPC forum discussion on this pairing highlights that '21365 includes multiple approaches' — if orbital access was used as one of those approaches, separate billing of 67450 is not appropriate. If a true standalone orbitotomy was performed for a separate indication, document it thoroughly and append modifier 59 or XS.

03Does 21365 support co-surgeon billing?

Yes, modifier 62 is applicable when two surgeons with distinct expertise each perform a separate, non-overlapping portion of the procedure. Each must submit their own operative note detailing only their portion. Payers deny 62 when both notes read identically or describe the same work.

04What modifier applies for an unplanned return to the OR for a related complication within the 90-day global?

Modifier 78 — unplanned return to the OR for a procedure related to the original surgery, during the global period. Do not use modifier 79 (unrelated procedure) for a complication directly tied to the malar repair. Inverting these modifiers is a common audit finding.

05Is arch bar removal separately billable with 21365?

This is payer-variable. AAPC coding community discussions flag that arch bar removal (e.g., 20670) during the global period may be considered bundled by some payers. If billed separately, append modifier 78 if it's an unplanned return, or document that it represents a separately identifiable service. Confirm with your specific payer prior to billing.

06What is the terminated device procedure designation for 21365?

Per CMS transmittal data, 21365 carries a terminated device procedure amount. If the procedure is stopped early before hardware implantation, a device credit may apply. The amount is reflected in CMS quarterly update transmittals — verify the current figure in the applicable CMS transmittal.

Sources & references

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

Mira AI Scribe

Mira's AI scribe captures the fracture pattern description (comminuted vs. non-comminuted), foramina involvement, each surgical approach by name, fixation hardware details, and any intraoperative nerve findings from the surgeon's dictation. This prevents the most common 21365 downcode — an operative note that describes a complex repair but omits the specific complexity criteria that justify the code over 21360.

See how Mira captures CPT 21365 documentation