ICD-10-CM Billable Code

S28.211

Complete traumatic amputation of right breast

Clinical Classification Guidelines

Medical Intelligence & Overview

The complete traumatic amputation of the right breast is a severe injury resulting from a sudden, forceful event that causes the removal of the entire breast tissue. Such injuries are uncommon but can occur due to accidents, explosions, or other traumatic incidents. This condition requires immediate medical attention, not only to address the physical injury but also to manage potential complications and plan for reconstructive options if suitable.

Causes & Symptoms

Clinical Causes: Motor vehicle accidents involving severe trauma Explosive blasts or explosions near the chest area Industrial or construction accidents with heavy machinery Severe falls onto objects or surfaces that impact the chest Gunshot or stab wounds penetrating the breast tissue

Key Symptoms: Complete loss of the right breast tissue Severe bleeding from the injury site Intense pain in the chest and breast area Shock symptoms including dizziness, weakness, or fainting Possible damage to surrounding tissues, muscles, or ribs Signs of infection such as redness, swelling, or pus if treatment is delayed

Diagnostic & Treatment

Diagnosis Path: Diagnosis of a complete traumatic amputation of the right breast involves a thorough physical examination and medical history assessment. Imaging studies, such as X-rays or CT scans, are usually performed to evaluate the extent of soft tissue and bony injuries. These imaging techniques help identify any associated damage to the chest wall, ribs, or underlying organs. The clinical assessment focuses on controlling bleeding, preventing infection, and evaluating the patient’s overall stability.

Treatment Protocols: Treatment typically involves a combination of emergency interventions and surgical procedures. Immediate priorities include controlling bleeding, preventing infection, and stabilizing the patient. Surgical options may involve debridement of non-viable tissue, repair or removal of damaged structures, and planning for reconstructive surgery when appropriate. Antibiotics and tetanus prophylaxis are also essential components of care. In some cases, further reconstructive procedures, such as skin grafts or tissue flaps, may be recommended once the patient stabilizes.

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S28.211 a billable ICD-10 code?
Yes, S28.211 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S28.211?
Clinical documentation must specify the nature of Complete traumatic amputation of right breast and any associated comorbidities for accurate reporting.

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