CPT 21360Surgery

Opn tx dprsd malar fracture

CPT code 21360 covers the surgical repair of a depressed cheekbone (malar) fracture through an open procedure, where the surgeon makes an incision to access and reposition the broken bone fragments.

Showing rates for

National Average

Base Medicare rate

$516.57

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

7.19

PE RVU (NF)

7.74

MP RVU

1.04

Total RVU

15.97

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

NCCI bundling edits

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Billing tips

Clearly document whether internal fixation devices were used; if plates, screws, or wires were placed, code 21365 (with internal fixation) is the appropriate code and reimburses higher
Impact: Incorrect code selection between 21360 and 21365 can result in $200-400 reimbursement difference and potential downcoding
Document the specific approach used (intraoral, subciliary, upper blepharoplasty) and extent of depression in millimeters or centimeters to support medical necessity
Impact: Prevents 15-20% of denials related to insufficient documentation of fracture severity requiring open treatment
Verify that CT imaging showing depressed malar fracture is in the medical record before surgery and referenced in operative report
Impact: Missing or inadequate imaging documentation is responsible for 25% of medical necessity denials for facial fracture codes
For trauma cases, confirm E/M service on date of surgery was significant and separately identifiable before appending modifier 25 to same-day evaluation
Impact: Properly documented decision for surgery E/M can add $100-200 to total reimbursement when modifier 25 is supported
Bill facility and non-facility locations accurately; unlike many procedures, 21360 has identical facility and non-facility rates ($516.57), simplifying place of service coding
Impact: Eliminates common place of service errors that affect reimbursement for other surgical codes
When performed with other facial fracture repairs, list codes in descending RVU order with 21360 typically secondary; understand payer-specific multiple procedure reduction rules

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 21360 in 2025?

The 2025 Medicare national average reimbursement for CPT 21360 is $516.57 for both facility and non-facility settings. This rate is based on 15.97 total RVUs (7.19 work RVU, 7.74 PE RVU, 1.04 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT 21360 and 21365?

CPT 21360 is for open treatment of depressed malar fracture WITHOUT internal fixation, while 21365 includes internal fixation with plates, screws, or wires. If any hardware is placed to stabilize the fracture, 21365 must be billed instead of 21360, as it represents more extensive work and typically reimburses higher.

Can CPT 21360 be billed bilaterally with modifier 50?

Yes, if bilateral depressed malar fractures are treated during the same operative session, modifier 50 can be appended. This typically results in 150% reimbursement of the base rate. Alternatively, some payers require reporting the code twice with RT and LT modifiers instead of modifier 50.

What diagnosis codes are appropriate for billing CPT 21360?

Appropriate ICD-10 codes include S02.400A-S02.402B series for malar/zygomatic fractures. Specify laterality (right S02.40XA, left S02.41XA, unspecified S02.42XA) and episode of care (A for initial encounter for closed fracture, B for initial encounter for open fracture). The diagnosis must support the medical necessity for open surgical treatment.

How many RVUs is CPT code 21360 worth in 2025?

CPT 21360 has 15.97 total RVUs in 2025, consisting of 7.19 work RVUs, 7.74 practice expense RVUs (both facility and non-facility), and 1.04 malpractice RVUs. This relatively high RVU value reflects the complexity of open facial fracture surgery.

What documentation is required to avoid denials for CPT 21360?

Essential documentation includes pre-operative imaging (CT scan) showing depressed malar fracture with measurements, operative report detailing the open surgical approach with specific incision location, description of fracture elevation technique, confirmation that no internal fixation was used, and post-reduction assessment of alignment. Missing any of these elements increases denial risk significantly.

Can CPT 21360 be billed with orbital floor fracture repair codes?

CPT 21360 can potentially be billed with orbital floor fracture codes (21385-21395), but they are subject to NCCI edits and bundling rules. You must append modifier 59 or XS and document that the malar fracture reduction was a distinct procedure from the orbital floor work, typically performed through separate incisions or involving anatomically separate fracture sites. Without proper documentation, payers will bundle these services.