{"id":179914,"date":"2026-08-14T08:41:58","date_gmt":"2026-08-14T08:41:58","guid":{"rendered":"https:\/\/pabau.com\/?p=179914"},"modified":"2026-08-14T08:42:00","modified_gmt":"2026-08-14T08:42:00","slug":"cpt-code-21365","status":"publish","type":"post","link":"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/","title":{"rendered":"CPT Code 21365: Open treatment of complicated malar area fractures"},"content":{"rendered":"\n<script type=\"application\/ld+json\">{\"@context\":\"https:\/\/schema.org\",\"@type\":\"MedicalWebPage\",\"headline\":\"CPT Code 21365: Open treatment of complicated malar area fractures\",\"description\":\"CPT Code 21365 covers open treatment of complicated malar area fractures with internal fixation and multiple surgical approaches. Learn the code descriptor, ICD-10 pairings, modifiers, RVU values, fee schedule, and documentation requirements.\",\"url\":\"https:\/\/pabau.com\/procedure-codes\/cpt-code-21365\/\",\"audience\":{\"@type\":\"MedicalAudience\",\"audienceType\":\"Clinician\"},\"reviewedBy\":{\"@type\":\"Person\",\"name\":\"Dr Vanja Kitanova\",\"jobTitle\":\"Medical Reviewer\",\"affiliation\":{\"@type\":\"Organization\",\"name\":\"Pabau\"},\"knowsAbout\":[\"Medical Coding\",\"Clinical Documentation\",\"Healthcare Billing\",\"Clinical Safety\"],\"sameAs\":\"https:\/\/pabau.com\/blog\/author\/vanja\/\"},\"datePublished\":\"2026-08-08\",\"dateModified\":\"2026-08-14\"}<\/script>\n\n\n        <div id=\"key_takeaways\">\n            <div class=\"header\">\n                                    <img decoding=\"async\" src=\"https:\/\/pabau.com\/wp-content\/uploads\/2025\/12\/Key-Takeaways-Icon.svg\" alt=\"Key takeaways\" height=\"42\" width=\"42\">\n                                <h3>Key takeaways<\/h3>\n            <\/div>\n            <div class=\"list\">\n                                                            <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>CPT Code 21365 covers open treatment of a complicated malar area fracture, with internal fixation and multiple surgical approaches.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>The code only holds when the note documents comminution, cranial nerve foramen involvement, or a repair needing more than one incision.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Billing 21365 after a single-approach repair, or with no fixation hardware, is the most audited pattern in this code family.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Pair the claim with a laterality-specific code such as S02.40AA, and avoid S02.41XA, which is not a valid ICD-10 code.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Practice management software like Pabau keeps claims and clinical records in one system, so what you submit matches what you documented.<\/p>\n                        <\/div>\n                                                <\/div>\n        <\/div>\n    \n\n\n<p class=\"wp-block-paragraph\">CPT Code 21365 covers open treatment of a complicated fracture of the malar area, including the zygomatic arch and malar tripod. The repair must use internal fixation and more than one surgical approach. It sits above 21360 in the malar fracture family, and below the graft-inclusive 21366.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This reference covers the descriptor, the code family comparison, ICD-10 pairings, modifiers, reimbursement, and the operative note wording that supports the claim. It also flags two diagnosis codes that circulate in coding write-ups for this procedure and do not exist.<\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe title=\"CPT Coding Pitfalls Every Medical Practice Faces\" width=\"800\" height=\"450\" src=\"https:\/\/www.youtube.com\/embed\/vbvV5okdXKg?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 id=\"h-cpt-code-21365-definition-and-clinical-description\" class=\"wp-block-heading\">CPT Code 21365: Definition and clinical description<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">CPT Code 21365, as defined by the AMA CPT code set, reads:<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Field<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Detail<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">CPT code<\/td>\n<td style=\"padding:12px 16px;color:#374151\">21365<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Official descriptor<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod. With internal fixation and multiple surgical approaches<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Code family<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Fracture and dislocation procedures on the head, 21315 to 21497<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Typical billing providers<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Oral and maxillofacial surgeons, plastic surgeons, and ENT specialists, depending on payer and scope-of-practice rules<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Code status<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Active. Verify the current fiscal year status through the CMS fee schedule.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">Three elements in the descriptor decide the code. Remove any one of them and the procedure no longer maps to 21365.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>A complicated fracture:<\/strong> comminuted, or involving cranial nerve foramina<\/li>\n\n\n\n<li><strong>Internal fixation:<\/strong> the surgeon applies hardware, such as titanium miniplates and screws<\/li>\n\n\n\n<li><strong>Multiple surgical approaches:<\/strong> the repair needs more than one incision<\/li>\n<\/ul>\n\n\n\n<h2 id=\"h-clinical-indications-when-to-use-21365\" class=\"wp-block-heading\">Clinical indications: When to use 21365<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Not every open malar repair qualifies, and the clinical scenario decides the code. Practices running <a href=\"https:\/\/pabau.com\/industry\/plastic-surgery-emr\/\">plastic surgery EMR software<\/a> can build these criteria straight into the operative note template. The following presentations support 21365 billing:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Comminuted zygomatic arch fractures:<\/strong> multiple bone fragments requiring individual fixation across the arch or body<\/li>\n\n\n\n<li><strong>Malar tripod fractures with displacement:<\/strong> the zygomaticomaxillary complex is disrupted at the frontozygomatic suture, the zygomaticomaxillary buttress, and the zygomatic arch<\/li>\n\n\n\n<li><strong>Fractures involving cranial nerve foramina:<\/strong> displacement at the infraorbital foramen risks injury to the maxillary nerve and forces wider access<\/li>\n\n\n\n<li><strong>Comminuted malar body fractures:<\/strong> the malar eminence is fragmented and cannot be reduced through a single approach<\/li>\n\n\n\n<li><strong>Failed percutaneous treatment:<\/strong> reduction under CPT 21355 left the complex displaced, so the repair converts to open fixation<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">If the fracture is not comminuted, spares the cranial nerve foramina, and reduces through a single incision, code 21360 instead. The complexity threshold is a documentation question as much as a clinical one.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Most of these injuries arrive from assaults, motor vehicle collisions, and contact sports, so the first assessment often happens outside the surgical practice. <a href=\"https:\/\/pabau.com\/industry\/sports-medicine-software\/\">Sports medicine practices<\/a> that record the mechanism and the initial exam give the surgeon the complexity evidence the claim later needs.<\/p>\n\n\n\n<h2 id=\"h-cpt-21365-vs-21360-vs-21366-choosing-the-right-code\" class=\"wp-block-heading\">CPT 21365 vs 21360 vs 21366: Choosing the right code<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The malar fracture family runs from percutaneous treatment through bone grafting. Choosing the wrong member of that family is one of the most audited upcoding patterns in maxillofacial billing. The same graft-inclusive logic decides <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-21215\/\">CPT 21215<\/a> for a mandibular bone graft.<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">CPT code<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Descriptor summary<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Internal fixation?<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Multiple approaches?<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Bone graft?<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">21360<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Open treatment of a depressed malar area fracture, without internal fixation<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Not required<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">21365<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Open treatment of a complicated malar area fracture, comminuted or involving cranial nerve foramina<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Yes, required<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Yes, required<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">21366<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Open treatment of a complicated malar area fracture, with internal fixation and bone graft<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Yes, required<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Yes, required<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Yes, and obtaining the graft is included<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">Work the decision in order. Is the fracture complicated by AMA criteria? Did the surgeon apply fixation hardware? Was a bone graft harvested and placed? Those three answers move you from 21360 through 21365 to 21366.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Billing 21365 when only one surgical approach was used, or when no internal fixation was placed, is an auditable claim regardless of fracture severity.<\/p>\n\n\n\n<h2 id=\"h-icd-10-codes-commonly-paired-with-21365\" class=\"wp-block-heading\">ICD-10 codes commonly paired with 21365<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Every CPT 21365 claim needs a supporting ICD-10-CM diagnosis code, and payers expect both laterality and fracture type. A non-specific parent code is a common denial trigger. Check the <a href=\"https:\/\/www.cms.gov\/medicare\/coding-billing\/icd-10-codes\" target=\"_blank\" rel=\"nofollow noopener\">CMS ICD-10-CM update files<\/a> each fiscal year for effective dates and code validity.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The sixth character of an S02.40 code carries the bone and the side, which is where most pairing errors start:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>A and B:<\/strong> malar fracture, right side and left side<\/li>\n\n\n\n<li><strong>C and D:<\/strong> maxillary fracture, right side and left side<\/li>\n\n\n\n<li><strong>E and F:<\/strong> zygomatic fracture, right side and left side<\/li>\n\n\n\n<li><strong>0, 1, and 2:<\/strong> the same three bones with the side unspecified<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Two mislabeled codes circulate widely for this procedure. S02.40CA is a right maxillary fracture, not a left malar one. S02.41XA is not a valid code at all, because S02.41 is the LeFort fracture family.<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">ICD-10-CM code<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Description<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Notes<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">S02.400A<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Malar fracture, unspecified side, initial encounter for closed fracture<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Use only where the note genuinely omits the side. Payers may deny it.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">S02.40AA<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Malar fracture, right side, initial encounter for closed fracture<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The right-sided pairing for most 21365 claims.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">S02.40BA<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Malar fracture, left side, initial encounter for closed fracture<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The left-sided pairing. B is left, not right.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">S02.40EA<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Zygomatic fracture, right side, initial encounter for closed fracture<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Use when the zygomatic arch or body is the primary fracture site.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">S02.40FA<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Zygomatic fracture, left side, initial encounter for closed fracture<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The same rule on the left side.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">S02.402A<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Zygomatic fracture, unspecified side, initial encounter for closed fracture<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The open-fracture equivalent is S02.402B.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">The seventh character sets the encounter and the wound. Use &#8222;A&#8220; for the initial encounter with a closed fracture, and &#8222;B&#8220; when the fracture is open. &#8222;D&#8220; covers a subsequent encounter with routine healing, and &#8222;S&#8220; marks a sequela.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Most surgical claims use &#8222;A,&#8220; and a sequela code on a first operative encounter is an instant denial. Codes like <a href=\"https:\/\/pabau.com\/diagnostic-codes\/icd-10-code-s62630k\/\">S62.630K<\/a> and <a href=\"https:\/\/pabau.com\/diagnostic-codes\/icd-10-code-s066x1d\/\">S06.6X1D<\/a> show how much that single character changes.<\/p>\n\n\n\n<h2 id=\"h-modifiers-that-apply-to-21365\" class=\"wp-block-heading\">Modifiers that apply to 21365<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Modifier selection drives both reimbursement and audit exposure, and Medicare rules often differ from commercial payer rules. <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-11011\/\">CPT 11011<\/a> shows the same modifier logic applied to open fracture debridement. The rules below cover the modifiers that attach to 21365 most often.<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Modifier<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">When to use it<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Key rule<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">-22, increased procedural services<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The procedure runs substantially beyond the typical case: extreme comminution, concurrent nerve decompression, or prolonged operative time<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Requires a detailed narrative in the operative note. Expect payer review, with no guaranteed increase.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">-50, bilateral procedure<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Bilateral zygomatic arch or malar fractures treated in the same operative session<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Bill once with -50. Some payers want two line items with -RT and -LT instead, so check first.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">-LT and -RT, laterality<\/td>\n<td style=\"padding:12px 16px;color:#374151\">A unilateral procedure, where the modifier identifies the operative side<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Required by many payers even when the ICD-10 code carries the side. The two must match.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">-51, multiple procedures<\/td>\n<td style=\"padding:12px 16px;color:#374151\">21365 billed alongside another distinct surgical procedure, such as an orbital floor repair<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Attach it to the secondary procedure. Medicare then applies its multiple procedure payment reduction.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">-78, unplanned return to the OR<\/td>\n<td style=\"padding:12px 16px;color:#374151\">A related complication that needs a return to the operating room during the global period<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The Medicare global period for 21365 is 90 days. Document the complication and its link to the original repair.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">-80 and -82, surgical assistant<\/td>\n<td style=\"padding:12px 16px;color:#374151\">An assistant surgeon takes part in the procedure<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Confirm that assistant surgeon coverage is allowed for 21365 under the specific payer and plan.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<h2 id=\"h-reimbursement-and-fee-schedule-for-21365\" class=\"wp-block-heading\">Reimbursement and fee schedule for 21365<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Medicare pays 21365 through the Medicare Physician Fee Schedule, or MPFS, which assigns relative value units to each component of the work. The <a href=\"https:\/\/www.cms.gov\/medicare\/physician-fee-schedule\/search\/overview\" target=\"_blank\" rel=\"nofollow noopener\">CMS fee schedule tool<\/a> carries the current national and locality-specific rates.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Rates move with every annual update, so check the current fiscal year before you quote a figure. <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-22318\/\">CPT 22318<\/a> sits in the same fracture repair territory if you want an RVU comparison.<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">RVU component<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Description<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Notes<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Work RVU<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Physician time and intensity<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The largest component. It reflects the operative complexity of 21365 against 21360.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Practice expense RVU<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Overhead costs, which differ by place of service<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The facility rate is lower than the non-facility rate.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Malpractice RVU<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Professional liability component<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Reflects the risk profile of open surgical repair with internal fixation.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Geographic adjustment<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The geographic practice cost index applied to each RVU component<\/td>\n<td style=\"padding:12px 16px;color:#374151\">High-cost localities receive higher adjusted rates, and rural areas lower ones.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">National Medicare rate<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Total RVUs multiplied by the annual conversion factor<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Verify the current factor and total RVUs through dollar amounts change annually.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">Facility and non-facility reimbursement differ, and the place of service decides which one applies. When 21365 is performed in a hospital or ambulatory surgical center, the surgeon bills the physician component only. The facility bills its own claim.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In a non-facility setting the surgeon&#8217;s payment is higher, because it absorbs overhead that would otherwise sit with the facility. Most complicated malar repairs happen in facility settings, so the facility rate usually applies.<\/p>\n\n\n        <div id=\"pro_tip\">\n            <div class=\"img\">\n                <svg width=\"42\" height=\"42\" viewBox=\"0 0 42 42\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                    <path fill-rule=\"evenodd\" clip-rule=\"evenodd\"\n                        d=\"M12.6383 19.5238C12.6632 21.2071 12.8734 22.9926 12.0685 24.5523C11.0341 26.8917 8.45076 28.169 7.56292 30.5918C6.63082 33.1061 7.19505 36.185 9.31371 37.9786C10.929 39.5678 13.4183 39.9873 15.6061 39.5463C17.4592 39.073 19.1049 37.8388 19.9706 36.1608C20.781 34.7141 20.7866 32.9904 20.5293 31.3985C20.1006 29.3092 18.3775 27.8705 16.9807 26.362C14.8814 24.1005 14.6684 20.6854 15.595 17.8915C16.4331 15.4768 19.0026 14.2344 20.0425 11.9461C20.7202 10.6769 20.7506 9.20327 20.6068 7.81304C20.1864 5.40098 18.3139 3.23631 15.8716 2.56674C13.9742 2.03969 11.8224 2.30052 10.1739 3.37614C8.70522 4.34688 7.5878 5.86618 7.28356 7.58178C6.76081 9.82981 7.53525 12.2822 9.20307 13.9118C10.7658 15.4741 12.4806 17.2273 12.6383 19.5238Z\"\n                        fill=\"#2BADD4\" \/>\n                    <path fill-rule=\"evenodd\" clip-rule=\"evenodd\"\n                        d=\"M22.7048 19.8387C22.6822 22.3279 24.4507 24.6234 26.7493 25.4682C28.0531 25.961 29.4725 25.9183 30.7989 25.5487C32.0575 24.9955 33.301 24.2237 34.0069 23.0092C34.8384 21.5811 35.2982 19.8286 34.7832 18.2094C34.3611 16.2507 32.8739 14.6541 31.0275 13.9426C28.6736 12.9595 25.8073 13.7942 24.1719 15.7001C23.2022 16.8366 22.6143 18.3326 22.7048 19.8387Z\"\n                        fill=\"#2BADD4\" \/>\n                <\/svg>\n            <\/div>\n            <div class=\"text\">\n                <h3>Pro Tip<\/h3>\n                <p>Before submitting a CPT 21365 claim, pull the current year RVU values from the CMS fee schedule and your payer&#8217;s contract rate schedule. The difference between the Medicare rate and a commercial contracted rate can be substantial. Track both in your billing system&#8217;s reporting module to spot underpayment patterns across your surgical volume.<\/p>\n            <\/div>\n        <\/div>\n    \n\n\n<h2 id=\"h-documentation-requirements-for-21365\" class=\"wp-block-heading\">Documentation requirements for 21365<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This is where most 21365 claims fail at audit. <a href=\"https:\/\/pabau.com\/blog\/medical-forms-at-your-healthcare-practice\/\">Operative note documentation standards<\/a> require each supporting element to be stated outright, not implied. <a href=\"https:\/\/pabau.com\/blog\/hipaa-compliance-software\/\">HIPAA-compliant clinical documentation<\/a> also has to stay accurate, complete, and retrievable whenever a payer asks.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The operative note for a 21365 claim has to contain all of the following, explicitly stated:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>A fracture complexity statement:<\/strong> describe the pattern in language that maps to &#8222;complicated,&#8220; such as &#8222;comminuted with four fragments&#8220; or &#8222;involving the infraorbital foramen&#8220;<\/li>\n\n\n\n<li><strong>Every surgical approach, named:<\/strong> list each incision site, such as the upper buccal sulcus, the lateral brow, and the subciliary lower lid. Give the anatomical reason for each one.<\/li>\n\n\n\n<li><strong>Internal fixation detail:<\/strong> name the hardware, the screw count, and the technique, for example two 1.5 mm titanium miniplates at the frontozygomatic suture<\/li>\n\n\n\n<li><strong>Reduction confirmation:<\/strong> record how anatomic reduction was assessed, whether by inspection, palpation, or intraoperative imaging<\/li>\n\n\n\n<li><strong>A nerve involvement note:<\/strong> where cranial nerve foramina were involved, document preoperative nerve status and any decompression performed<\/li>\n\n\n\n<li><strong>Wound closure:<\/strong> document layered closure with suture types and sizes for each approach site<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">A note reading &#8222;open reduction internal fixation of ZMC fracture performed&#8220; will not survive post-payment audit. It gives the reviewer no approach count, no hardware, and no complexity rationale. <a href=\"https:\/\/pabau.com\/features\/patient-intake-software\/\">Digital clinical forms<\/a> with structured operative fields capture each element while the surgeon is still in the note.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/cdn.pabau.com\/cdn\/attachments\/pulse\/content-engine\/billing_codes\/cpt-code-21365\/digital-forms.webp\" alt=\"Pabau medical forms builder showing a template library and a patient form preview\"\/><figcaption class=\"wp-element-caption\"><em>Pabau&#8217;s medical forms builder turns the 21365 documentation checklist into required fields, so nothing is missed at the point of charting.<\/em><\/figcaption><\/figure>\n\n\n\n<div style=\"height:35px;width:800px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 id=\"h-common-billing-errors-and-claim-denials\" class=\"wp-block-heading\">Common billing errors and claim denials<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">These are the failure patterns that show up most often when a malar fracture claim goes to post-payment review. Practices with structured <a href=\"https:\/\/pabau.com\/blog\/plastic-surgery-practice-emr-software\/\">surgical billing workflows<\/a> catch them before submission rather than after a denial.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Upcoding from 21360:<\/strong> billing 21365 when no internal fixation was placed, or when only a single surgical approach was used. This is the highest-frequency audit trigger in the malar code family.<\/li>\n\n\n\n<li><strong>A non-specific ICD-10 code:<\/strong> using S02.400A when the operative note names the side. Payers increasingly require the laterality-specific code.<\/li>\n\n\n\n<li><strong>The wrong seventh character:<\/strong> using &#8222;D&#8220; or &#8222;S&#8220; on the initial surgical claim.<\/li>\n\n\n\n<li><strong>Modifier omission:<\/strong> billing bilateral procedures without -50, or without splitting them into -LT and -RT line items per payer instructions.<\/li>\n\n\n\n<li><strong>Global period violations:<\/strong> billing a related postoperative service inside the 90-day global period without the appropriate modifier.<\/li>\n\n\n\n<li><strong>A missing narrative for -22:<\/strong> appending the modifier without explaining what made the procedure more complex than the 21365 baseline.<\/li>\n\n\n\n<li><strong>Unbundling:<\/strong> billing separately for services already inside the 21365 global package, such as routine postoperative visits.<\/li>\n<\/ul>\n\n\n\n<h2 id=\"h-anesthesia-codes-paired-with-21365\" class=\"wp-block-heading\">Anesthesia codes paired with 21365<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Complicated malar fracture repair is normally done under general anesthesia, given the operative complexity and the multiple approaches. The anesthesia provider bills from the 00100 to 01999 range, not from 21365 itself. Check current descriptors against the <a href=\"https:\/\/www.aapc.com\/codes\/cpt-codes-range\/\" target=\"_blank\" rel=\"nofollow noopener\">AAPC code range lookup<\/a> before pairing anything.<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Anesthesia CPT<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Description<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Applicability<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr style=\"border-bottom:1px solid #E8ECF0\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">00190<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Anesthesia for procedures on facial bones or skull, not otherwise specified<\/td>\n<td style=\"padding:12px 16px;color:#374151\">The usual pairing for 21365. Confirm it with the anesthesia group.<\/td>\n<\/tr>\n<tr style=\"border-bottom:1px solid #E8ECF0;background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">00192<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Anesthesia for procedures on facial bones or skull, radical surgery including prognathism<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Carries more base units than 00190. It applies only where the record documents radical surgery.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">The surgeon&#8217;s billing team does not submit the anesthesia code. Even so, the anesthesia record and the operative note should describe the same procedure.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If the anesthesia record reads simpler than the surgical record, a payer can question both claims. <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-01758\/\">CPT 01758<\/a> follows the same base-unit and time logic on another bone procedure.<\/p>\n\n\n        <div id=\"pro_tip\">\n            <div class=\"img\">\n                <svg width=\"42\" height=\"42\" viewBox=\"0 0 42 42\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                    <path fill-rule=\"evenodd\" clip-rule=\"evenodd\"\n                        d=\"M12.6383 19.5238C12.6632 21.2071 12.8734 22.9926 12.0685 24.5523C11.0341 26.8917 8.45076 28.169 7.56292 30.5918C6.63082 33.1061 7.19505 36.185 9.31371 37.9786C10.929 39.5678 13.4183 39.9873 15.6061 39.5463C17.4592 39.073 19.1049 37.8388 19.9706 36.1608C20.781 34.7141 20.7866 32.9904 20.5293 31.3985C20.1006 29.3092 18.3775 27.8705 16.9807 26.362C14.8814 24.1005 14.6684 20.6854 15.595 17.8915C16.4331 15.4768 19.0026 14.2344 20.0425 11.9461C20.7202 10.6769 20.7506 9.20327 20.6068 7.81304C20.1864 5.40098 18.3139 3.23631 15.8716 2.56674C13.9742 2.03969 11.8224 2.30052 10.1739 3.37614C8.70522 4.34688 7.5878 5.86618 7.28356 7.58178C6.76081 9.82981 7.53525 12.2822 9.20307 13.9118C10.7658 15.4741 12.4806 17.2273 12.6383 19.5238Z\"\n                        fill=\"#2BADD4\" \/>\n                    <path fill-rule=\"evenodd\" clip-rule=\"evenodd\"\n                        d=\"M22.7048 19.8387C22.6822 22.3279 24.4507 24.6234 26.7493 25.4682C28.0531 25.961 29.4725 25.9183 30.7989 25.5487C32.0575 24.9955 33.301 24.2237 34.0069 23.0092C34.8384 21.5811 35.2982 19.8286 34.7832 18.2094C34.3611 16.2507 32.8739 14.6541 31.0275 13.9426C28.6736 12.9595 25.8073 13.7942 24.1719 15.7001C23.2022 16.8366 22.6143 18.3326 22.7048 19.8387Z\"\n                        fill=\"#2BADD4\" \/>\n                <\/svg>\n            <\/div>\n            <div class=\"text\">\n                <h3>Pro Tip<\/h3>\n                <p>Cross-reference your 21365 operative note with the anesthesia record before either claim goes out. Differences in procedure description, timing, or complexity level between the two records are a common trigger for coordinated payer audits in surgical specialties.<\/p>\n            <\/div>\n        <\/div>\n    \n\n\n<h2 id=\"h-how-pabau-keeps-21365-claims-matched-to-the-operative-note\" class=\"wp-block-heading\">How Pabau keeps 21365 claims matched to the operative note<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">In most surgical practices the operative note lives in one system and the claim is built in another. Someone reads the note, retypes the codes into a billing tool, and hopes the two still agree at audit.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Practice management software like Pabau keeps both in one record. The patient&#8217;s insurer and policy sit on their record, so every invoice routes to the right payer without re-keying. <a href=\"https:\/\/pabau.com\/features\/claims-management-software\/\">Claims management<\/a> then submits electronically, tracks each claim through submitted, processing, paid, or error, and posts the remittance against the invoice.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pabau also runs validation checks before a claim can go out. A missing membership number or authorization code stops the send, instead of coming back weeks later as a rejection.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Structured forms hold the fixation detail and the approach list that a 21365 note needs. Your team spends its time on the surgery schedule, not on reworking denials.<\/p>\n\n\n        <div id=\"book_a_demo\">\n            <div class=\"left-side\">\n                <div class=\"logo\">\n                    <img decoding=\"async\"\n                        src=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/01\/Logo.svg\"\n                        alt=\"Logo\"\n                        loading=\"lazy\"\n                    \/>\n                <\/div>\n\n                <h3 class=\"heading\">\n                    Keep every claim tied to its clinical record                <\/h3>\n\n                <p class=\"description\">\n                    Pabau brings claims, invoices, and clinical records into one system. Submit electronically, watch every claim&#8217;s status, and fix missing details before a payer rejects them.                <\/p>\n\n                <div class=\"button-group\">\n                    <a href=\"\/book-demo\/\" class=\"btn btn-scale-effect btn-cta-color btn-md\">\n                        <span class=\"btn-text\">Book a demo<\/span>\n                        <div class=\"btn-icon btn-icon-right\" aria-hidden=\"true\">\n                            <svg\n                                width=\"14\"\n                                height=\"12\"\n                                viewBox=\"0 0 14 12\"\n                                fill=\"none\"\n                                xmlns=\"http:\/\/www.w3.org\/2000\/svg\"\n                            >\n                                <path\n                                    d=\"M0.75 4.77295C0.335786 4.77295 0 5.10874 0 5.52295C0 5.93716 0.335786 6.27295 0.75 6.27295V5.52295V4.77295ZM13.2803 6.05328C13.5732 5.76039 13.5732 5.28551 13.2803 4.99262L8.50736 0.219648C8.21447 -0.073245 7.73959 -0.073245 7.4467 0.219648C7.15381 0.512542 7.15381 0.987415 7.4467 1.28031L11.6893 5.52295L7.4467 9.76559C7.15381 10.0585 7.15381 10.5334 7.4467 10.8263C7.73959 11.1191 8.21447 11.1191 8.50736 10.8263L13.2803 6.05328ZM0.75 5.52295V6.27295L12.75 6.27295V5.52295V4.77295L0.75 4.77295V5.52295Z\"\n                                    fill=\"currentColor\"\n                                ><\/path>\n                            <\/svg>\n                        <\/div>\n                    <\/a>\n                <\/div>\n            <\/div>\n\n            <div class=\"right-side\">\n                <img decoding=\"async\"\n                    src=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/01\/Home-Page-Concept-4.webp\"\n                    alt=\"Pabau claims dashboard for surgical billing\"\n                    loading=\"lazy\"\n                \/>\n            <\/div>\n        <\/div>\n        \n\n\n<h2 id=\"h-conclusion\" class=\"wp-block-heading\">Conclusion<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The billing risk in 21365 sits in the operative note rather than the claim form. A reviewer reads the note and either finds comminution, hardware, and two approaches, or does not.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">So write the note for that reader. Name the fragments, name the plates and screws, name every incision, and pair the claim with the right laterality code. Do that and 21365 stops being a code you argue about after payment.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Fixing this while the note is still open costs a few extra lines. Fixing it at appeal costs weeks. <a href=\"https:\/\/pabau.com\/book-demo\/\">Book a demo<\/a> to see how Pabau keeps surgical claims and clinical records in step.<\/p>\n\n\n        <div id=\"expert_picks\">\n            <div class=\"header\">\n                                    <img decoding=\"async\" src=\"https:\/\/pabau.com\/wp-content\/uploads\/2025\/11\/Expert-Picks.svg\" alt=\"Continue your research\" height=\"42\" width=\"42\">\n                                <h3>Continue your research<\/h3>\n            <\/div>\n            <div class=\"content\">\n                                                            <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Billing a code that may no longer exist?<\/strong> <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-19324\/\">CPT 19324<\/a> shows what happens when a code is deleted and which code replaces it.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Coding a graft harvest as a separate line?<\/strong> <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-20939\/\">CPT 20939<\/a> covers the add-on rules for bone marrow aspiration in spine surgery.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Need the ground rules for add-on codes?<\/strong> <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-11008\/\">CPT 11008<\/a> walks through add-on billing and the documentation each line needs.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Coding a later encounter rather than the repair?<\/strong> <a href=\"https:\/\/pabau.com\/diagnostic-codes\/icd-10-code-s63615s\/\">S63.615S<\/a> shows how the sequela character changes a diagnosis code.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Working on another facial bone claim?<\/strong> <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-21497\/\">CPT 21497<\/a> covers interdental wiring, its modifiers, and reimbursement.<\/p>\n                        <\/div>\n                                                <\/div>\n        <\/div>\n    \n\n\n<h2 id=\"h-frequently-asked-questions\" class=\"wp-block-heading\">Frequently asked questions<\/h2>\n\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1786626572880\"><h3 class=\"schema-faq-question\">What is CPT Code 21365 used for?<\/h3> <p class=\"schema-faq-answer\">CPT Code 21365 covers open surgical treatment of a complicated malar area fracture, including the zygomatic arch and malar tripod. It requires internal fixation and multiple surgical approaches. The fracture must be comminuted, involve cranial nerve foramina, or need more than one incision for adequate reduction. Oral and maxillofacial surgeons, plastic surgeons, and ENT specialists bill it, subject to payer and scope-of-practice rules.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1786626572881\"><h3 class=\"schema-faq-question\">What is the Medicare reimbursement rate for CPT 21365?<\/h3> <p class=\"schema-faq-answer\">Medicare pays 21365 by multiplying its total relative value units by the annual conversion factor. Work, practice expense, and malpractice RVUs make up that total. The result is then adjusted for the geographic practice cost index in your locality. Rates change each year with the CMS fee schedule update, so check the current year for your locality and place of service.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1786626572882\"><h3 class=\"schema-faq-question\">What modifiers apply to CPT Code 21365?<\/h3> <p class=\"schema-faq-answer\">The modifiers that attach to 21365 most often are -22, -50, -LT, -RT, -51, and -78. Modifier -22 needs an operative narrative explaining the extra complexity. Use -50 for a bilateral repair, or -LT and -RT if your payer wants separate line items. Medicare applies its multiple procedure payment reduction when -51 is used. Modifier -78 covers an unplanned return to the operating room inside the 90-day global period.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1786626572883\"><h3 class=\"schema-faq-question\">What ICD-10 codes are commonly paired with CPT 21365?<\/h3> <p class=\"schema-faq-answer\">Use a laterality-specific malar or zygomatic fracture code from the S02.40 subcategory. S02.40AA is a right malar fracture and S02.40BA is a left malar fracture, both for an initial encounter with a closed fracture. For the zygomatic bone, use S02.40EA on the right and S02.40FA on the left. Avoid the unspecified parent code S02.400A where the note names the side. S02.41XA is not a valid code, because S02.41 is the LeFort fracture family.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1786626572884\"><h3 class=\"schema-faq-question\">How does CPT 21365 differ from CPT 21360 and 21366?<\/h3> <p class=\"schema-faq-answer\">CPT 21360 covers open treatment of a depressed malar fracture without internal fixation, and it does not require multiple approaches. CPT 21365 adds fixation hardware and multiple surgical approaches, for a comminuted fracture or one involving cranial nerve foramina. CPT 21366 goes further again, adding a bone graft that the surgeon harvests and places. The operative note decides which one applies. Fixation hardware means at least 21365, and a placed graft means 21366.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1786626572885\"><h3 class=\"schema-faq-question\">What is a ZMC fracture, and does CPT 21365 cover it?<\/h3> <p class=\"schema-faq-answer\">A ZMC fracture, or zygomaticomaxillary complex fracture, is also called a malar tripod or trimalar fracture. It disrupts the three articulations of the zygomatic complex: the frontozygomatic suture, the zygomaticomaxillary buttress, and the zygomatic arch. CPT 21365 applies when that fracture needs open reduction, internal fixation, and multiple surgical approaches. Not every ZMC fracture qualifies. A minimally displaced fracture managed without fixation hardware may code to 21360 instead.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>CPT Code 21365 covers open treatment of a complicated fracture of the malar area, including the zygomatic arch and malar tripod. The repair must use internal fixation and more than one surgical approach. It sits above 21360 in the malar fracture family, and below the graft-inclusive 21366. This reference covers the descriptor, the code family [&hellip;]<\/p>\n","protected":false},"author":83,"featured_media":179909,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_yoast_wpseo_linkdex":"88","_yoast_wpseo_content_score":"30","_yoast_wpseo_is_cornerstone":"","_yoast_wpseo_keywordsynonyms":"[\"\",\"\",\"\",\"\"]","_yoast_wpseo_focuskw_text_input":"","_seo_original_html":"","footnotes":""},"categories":[1433,1546],"tags":[1602,2775,4199],"class_list":["post-179914","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-billing-codes","category-cpt-codes","tag-cpt-modifiers","tag-fracture-management","tag-plastic-surgery-billing"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.2 (Yoast SEO v28.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>CPT Code 21365: Malar fracture billing and 2026 fee schedule<\/title>\n<meta name=\"description\" content=\"CPT 21365 covers open treatment of a complicated malar fracture with fixation and multiple approaches. Codes, modifiers, and RVUs.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/\" \/>\n<meta property=\"og:locale\" content=\"de_DE\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"CPT Code 21365: Malar fracture billing and 2026 fee schedule\" \/>\n<meta property=\"og:description\" content=\"CPT 21365 covers open treatment of a complicated malar fracture with fixation and multiple approaches. Codes, modifiers, and RVUs.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/\" \/>\n<meta property=\"og:site_name\" content=\"Pabau\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/Pabau\/\" \/>\n<meta property=\"article:published_time\" content=\"2026-08-14T08:41:58+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-08-14T08:42:00+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/08\/cpt-code-21365.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1200\" \/>\n\t<meta property=\"og:image:height\" content=\"630\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Anja Dodevska\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@pabaucrm\" \/>\n<meta name=\"twitter:site\" content=\"@pabaucrm\" \/>\n<meta name=\"twitter:label1\" content=\"Verfasst von\" \/>\n\t<meta name=\"twitter:data1\" content=\"Anja Dodevska\" \/>\n\t<meta name=\"twitter:label2\" content=\"Gesch\u00e4tzte Lesezeit\" \/>\n\t<meta name=\"twitter:data2\" content=\"13\u00a0Minuten\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/\"},\"author\":{\"name\":\"Anja Dodevska\",\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/#\\\/schema\\\/person\\\/f2e43b25ed02313e8781f0f4507398b9\"},\"headline\":\"CPT Code 21365: Open treatment of complicated malar area fractures\",\"datePublished\":\"2026-08-14T08:41:58+00:00\",\"dateModified\":\"2026-08-14T08:42:00+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/\"},\"wordCount\":2720,\"publisher\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/pabau.com\\\/wp-content\\\/uploads\\\/2026\\\/08\\\/cpt-code-21365.webp\",\"keywords\":[\"Cpt Modifiers\",\"Fracture management\",\"plastic surgery billing\"],\"articleSection\":[\"Billing Codes\",\"CPT Codes\"],\"inLanguage\":\"de\"},{\"@type\":[\"WebPage\",\"FAQPage\"],\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/\",\"url\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/\",\"name\":\"CPT Code 21365: Malar fracture billing and 2026 fee schedule\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/de\\\/procedure-codes\\\/cpt-code-21365\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/pabau.com\\\/wp-content\\\/uploads\\\/2026\\\/08\\\/cpt-code-21365.webp\",\"datePublished\":\"2026-08-14T08:41:58+00:00\",\"dateModified\":\"2026-08-14T08:42:00+00:00\",\"description\":\"CPT 21365 covers open treatment of a complicated malar fracture with fixation and multiple approaches. 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Oral and maxillofacial surgeons, plastic surgeons, and ENT specialists bill it, subject to payer and scope-of-practice rules.","inLanguage":"de"},"inLanguage":"de"},{"@type":"Question","@id":"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/#faq-question-1786626572881","position":2,"url":"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/#faq-question-1786626572881","name":"What is the Medicare reimbursement rate for CPT 21365?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Medicare pays 21365 by multiplying its total relative value units by the annual conversion factor. Work, practice expense, and malpractice RVUs make up that total. The result is then adjusted for the geographic practice cost index in your locality. 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Modifier -78 covers an unplanned return to the operating room inside the 90-day global period.","inLanguage":"de"},"inLanguage":"de"},{"@type":"Question","@id":"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/#faq-question-1786626572883","position":4,"url":"https:\/\/pabau.com\/de\/procedure-codes\/cpt-code-21365\/#faq-question-1786626572883","name":"What ICD-10 codes are commonly paired with CPT 21365?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Use a laterality-specific malar or zygomatic fracture code from the S02.40 subcategory. S02.40AA is a right malar fracture and S02.40BA is a left malar fracture, both for an initial encounter with a closed fracture. For the zygomatic bone, use S02.40EA on the right and S02.40FA on the left. Avoid the unspecified parent code S02.400A where the note names the side. 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