CPT 21356Surgery

Opn tx dprsd zygomatic arch

CPT 21356 is for surgically repairing a broken cheekbone (zygomatic arch) through an open incision, where the bone has been pushed inward or depressed. This procedure requires the surgeon to make an incision, access the fractured bone, and reposition it to restore normal facial structure.

Showing rates for

National Average

Base Medicare rate

$534.69

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

Work RVU

4.83

PE RVU (NF)

10.82

MP RVU

0.88

Total RVU

16.53

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Verify facility versus non-facility status before billing - the $137.47 difference (26% higher) in Medicare reimbursement depends on place of service code accuracy
Impact: Incorrect POS coding can result in $137.47 underpayment per case or trigger recoupment if incorrectly billed at non-facility rate
Document whether internal fixation was used - if plates, screws, or wires were required, consider whether 21365 (open treatment with external fixation) is more appropriate
Impact: Incorrect code selection between 21356 and 21365 can result in 15-30% payment variance; 21365 typically reimburses higher due to greater complexity
Clearly differentiate isolated zygomatic arch fractures from zygomaticomaxillary complex (ZMC/tripod) fractures in documentation - ZMC fractures require different codes (21365-21366)
Impact: Coding a complex ZMC fracture as simple arch fracture (21356) results in underpayment of $200-400; conversely, upcoding can trigger audit and recoupment
Bill laterality modifier (LT/RT) on first claim submission - this is required by most payers and missing modifiers delay payment by 15-30 days on average
Impact: Prevents automatic denials and resubmission delays; some payers deny claims outright rather than requesting clarification
When performed with other facial fracture repairs, sequence codes by RVU value with highest first to maximize reimbursement under multiple procedure rules
Impact: Proper sequencing prevents unnecessary 50% reduction on the higher-valued procedure; can preserve $200+ per case when multiple facial codes billed
Verify global period (90 days) before billing E/M services during postoperative care - only separately identifiable, unrelated services or complications are billable

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 21356 in 2025?

Medicare pays $534.69 for CPT 21356 in non-facility settings and $397.22 in facility settings based on the 2025 Physician Fee Schedule national average. The facility rate is lower because overhead costs are covered separately through facility fees. Actual payment may vary by geographic locality based on the GPCI adjustment.

What is the difference between CPT 21355 and 21356?

CPT 21355 is for closed treatment of a depressed zygomatic arch fracture (without incision), typically using percutaneous instruments or temporal approach without direct visualization. CPT 21356 is for open treatment requiring an incision with direct visualization of the fracture. The open approach (21356) reimburses significantly higher due to increased complexity and invasiveness.

How many RVUs is CPT code 21356 worth?

CPT 21356 has a total of 16.53 RVUs in 2025, consisting of 4.83 work RVUs, 10.82 practice expense RVUs (non-facility), and 0.88 malpractice RVUs. In facility settings, the PE RVU drops to 6.57, resulting in different total RVUs. This is considered a moderate-complexity surgical procedure based on RVU values.

Can CPT 21356 be billed bilaterally?

Yes, bilateral zygomatic arch fractures can occur and would require bilateral surgical treatment. Bill 21356 twice with LT and RT modifiers, or use modifier 50 depending on payer preference. Most payers reimburse the second side at 50% of the allowable fee. Documentation must clearly show separate fractures requiring independent surgical treatment on each side.

What is the global period for CPT 21356?

CPT 21356 has a 90-day global surgical period. This means all routine postoperative care for 90 days after surgery is included in the surgical fee and cannot be billed separately. Only E/M services for unrelated conditions or documented complications can be billed during this period, typically with modifier 24.

Does CPT 21356 require prior authorization?

Prior authorization requirements vary by payer and plan. Medicare typically does not require prior authorization for 21356 when performed as acute trauma care, but many Medicare Advantage and commercial payers do require authorization, especially for delayed/elective repairs performed weeks after injury. Always verify specific payer requirements before scheduling surgery.

What diagnosis codes are appropriate for CPT 21356?

The most appropriate ICD-10 codes are S02.40XA (unspecified fracture of malar, maxillary and zygomatic bones, initial encounter), S02.41XA (malar fracture, initial), or S02.42XA (zygomatic fracture, initial) with laterality specified. Use 7th character A for initial treatment, D for subsequent encounters during healing. Additional external cause codes (V, W, X, Y codes) should document mechanism of injury for complete coding.