Complete traumatic amputation of right breast, sequela

This code signifies the long-term effects or complications arising from a complete traumatic amputation of the right breast. It indicates that the initial injury has healed, but the patient is now presenting for care related to the residual consequences of the amputation, such as scar tissue, phantom pain, or the need for reconstructive surgery.

Apply this code when a patient presents for follow-up care or treatment of conditions directly resulting from a past complete traumatic amputation of the right breast. This includes encounters for managing chronic pain, addressing cosmetic concerns, or planning for breast reconstruction years after the initial injury.

• Always use this code as a secondary diagnosis, with a code for the specific sequela (e.g., pain, scar) as the primary.
• Ensure documentation clearly states the amputation was complete and traumatic, and that the encounter is for a sequela.
• Do not use this code for the initial traumatic amputation; use an acute injury code for that scenario.