How To Use CPT Code 21356

CPT 21356 describes the open treatment of a depressed zygomatic arch fracture, specifically using the Gillies approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21356?

CPT 21356 is a code used to describe the open treatment of a depressed zygomatic arch fracture. This procedure involves accessing the fracture through an incision made behind the hairline. The provider repairs the fracture by realigning the bones and closing the incision.

2. Official Description

The official description of CPT code 21356 is: ‘Open treatment of depressed zygomatic arch fracture (e.g., Gillies approach).’ The Gillies approach refers to a surgical procedure for repairing a zygomatic arch fracture by utilizing an incision made behind the hairline.

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an approximately 3 cm incision above the zygomatic arch, behind the temporal hairline.
3. The provider dissects through the tissue to the superficial temporal fascia and the temporalis muscle fascia down to the zygomatic arch.
4. A periosteal elevator is used to lift and separate the tissue flaps, exposing the fractured zygomatic arch.
5. The provider manipulates the bones to realign them into the proper position.
6. The area is irrigated, checked for bleeding, and any instruments are removed.
7. The incision is closed.

4. Qualifying circumstances

CPT 21356 is used for patients with a depressed zygomatic arch fracture, which occurs when the bone is pushed inward due to blunt force trauma or a crush injury. The procedure is performed to repair the fracture and restore the normal alignment of the zygomatic arch. The Gillies approach is specifically used for this procedure.

5. When to use CPT code 21356

CPT code 21356 should be used when the provider performs an open treatment of a depressed zygomatic arch fracture using the Gillies approach. It is important to ensure that the procedure performed matches the description provided by the code.

6. Documentation requirements

To support a claim for CPT 21356, the provider must document the following information:

• Patient’s diagnosis of a depressed zygomatic arch fracture
• Description of the procedure performed, including the use of the Gillies approach
• Date of the procedure
• Details of the incision made and the steps taken to repair the fracture
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 21356, ensure that the procedure performed matches the description provided by the code. It is important to accurately document the details of the procedure to support the claim. There are no specific guidelines regarding reporting CPT code 21356 with other codes.

8. Historical information

CPT code 21356 was added to the Current Procedural Terminology system on January 1, 1993. There have been no updates to the code since its addition.

9. Examples

1. A patient sustains a depressed zygomatic arch fracture due to a fall. The provider performs an open treatment of the fracture using the Gillies approach.
2. A patient is involved in a car accident and suffers a depressed zygomatic arch fracture. The provider performs an open reduction and internal fixation of the fracture using CPT code 21356.
3. A patient presents with a depressed zygomatic arch fracture resulting from a sports injury. The provider performs an open treatment of the fracture, realigning the bones and closing the incision.
4. A patient is assaulted and sustains a depressed zygomatic arch fracture. The provider performs an open reduction of the fracture using the Gillies approach.
5. A patient is diagnosed with a depressed zygomatic arch fracture following a physical altercation. The provider performs an open treatment of the fracture, restoring the normal alignment of the zygomatic arch.
6. A patient falls from a height and suffers a depressed zygomatic arch fracture. The provider performs an open reduction and internal fixation of the fracture using CPT code 21356.
7. A patient is involved in a workplace accident and sustains a depressed zygomatic arch fracture. The provider performs an open treatment of the fracture, utilizing the Gillies approach to repair the fracture.
8. A patient is injured in a sporting event and presents with a depressed zygomatic arch fracture. The provider performs an open reduction of the fracture, manipulating the bones to realign them into the proper position.
9. A patient is involved in a motorcycle accident and suffers a depressed zygomatic arch fracture. The provider performs an open treatment of the fracture, irrigating the area and closing the incision.
10. A patient sustains a depressed zygomatic arch fracture due to a physical assault. The provider performs an open reduction and internal fixation of the fracture, using CPT code 21356 to bill for the procedure.