Perq tx malar fracture
CPT code 21355 covers percutaneous treatment of a malar (cheekbone) fracture, which involves fixing a broken cheekbone through the skin using minimally invasive techniques without making a large incision.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
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Billing tips
Always verify place of service code carefully - the $114.51 difference between facility (POS 22/24) and non-facility (POS 11) represents 26% higher reimbursement potential
Impact: Billing in correct setting maximizes reimbursement by up to $114.51 per procedure
Document percutaneous approach explicitly in operative report with specific mention of 'no open incision' and 'closed reduction' to differentiate from CPT 21360-21366 open procedures
Impact: Prevents downcoding to evaluation codes or upcoding denials that could result in 100% claim denial
Code separately for fluoroscopic guidance (76000) if used for fracture reduction and fixation placement, as it is not bundled with 21355
Impact: Additional $35-55 in reimbursement when fluoroscopy is medically necessary and documented
For bilateral malar fractures treated percutaneously in same session, append modifier 50 for bilateral procedure rather than billing twice with LT/RT
Impact: Bilateral modifier typically reimburses at 150% of single procedure rate (~$656.48 non-facility vs ~$875.30 for two separate codes)
When performed with other facial fracture repairs, check NCCI edits carefully - 21355 may be separately reportable if distinct anatomical site with modifier 59/XS documentation
Impact: Proper modifier use can preserve $323-438 in additional reimbursement for legitimate separate procedures
Submit claims within 90 days of service and include pre-operative imaging reports (CT facial bones) as supporting documentation to establish medical necessity
Reduces initial denial rate by approximately 15-20% based on insufficient documentation
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