Opn tx complx malar fx
CPT 21365 covers open surgical treatment of a complex cheekbone (malar) fracture, typically requiring incisions, fracture reduction, and internal fixation with plates and screws.
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
Document fracture complexity explicitly: number of fragments, degree of displacement (mm), involvement of multiple buttresses, and comminution pattern to justify 21365 over simpler codes 21360 or 21355
Impact: Prevents $400-600 downcoding to closed or simple open treatment codes; complexity documentation is primary audit target
Separately code and document orbital floor/wall repair (21385-21395) when performed, as these are not bundled with malar fixation
Impact: Additional $800-1200 in reimbursement when orbital involvement is properly documented and coded with modifier 51
Bill only once for 21365 even when multiple plates are used or multiple incisions made; the code includes all fixation at multiple sites of the malar complex
Impact: Prevents unbundling denials and potential fraud investigation; focus documentation on complexity rather than component count
Capture preoperative CT imaging interpretation in documentation and bill separately (70486-70488) when surgeon performs formal interpretation
Impact: Additional $100-300 when properly documented with separate dictation
For bilateral cases, ensure each side independently meets complexity criteria before applying modifier 50; document separately in operative note
Impact: Secures full bilateral reimbursement of $1590.96 versus risk of denial reducing to unilateral rate
Submit operative photos showing fracture complexity and reduction as attachments when billing with modifier 22 for extraordinary complexity
Impact: Increases modifier 22 approval rate from approximately 15% to 45-60% based on payer data
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