Abrasion of breast, unspecified breast, initial encounter

This code signifies a superficial injury to the skin of the breast, characterized by scraping or rubbing off of the epidermis. It indicates that the specific breast (left or right) affected by the abrasion was not documented.

This code is appropriate for initial treatment of a breast abrasion when the medical record does not specify which breast is injured. Examples include minor skin scrapes from friction, falls, or contact with rough surfaces where laterality is not noted.

• Only use this code when laterality (left or right breast) is truly unspecified in the documentation.
• For subsequent encounters for the same injury, use the appropriate seventh character (D for subsequent, S for sequela).
• Always review documentation for any mention of laterality before defaulting to an unspecified code.