Contusion of breast, unspecified breast, initial encounter

This code signifies a bruise or superficial injury to the breast tissue, resulting from direct trauma, without specifying which breast is affected. It indicates damage to capillaries and other small blood vessels, leading to localized bleeding under the skin. This diagnosis typically presents with pain, swelling, and discoloration of the breast.

Apply this code for a patient presenting with a newly sustained breast contusion, where the medical record does not specify laterality (left or right breast). Documentation should clearly indicate blunt force trauma to the breast and the initial encounter for this injury. This code is appropriate when the provider's assessment confirms a contusion without evidence of an open wound or more severe underlying injury.

• Ensure documentation explicitly states "unspecified breast" or lacks laterality for appropriate code assignment.
• Do not use this code if an open wound, such as an abrasion or laceration, is also present; refer to codes for open wounds of the breast.
• Verify that the encounter is indeed the "initial encounter" for this specific injury; subsequent care would require a different seventh character.