Posterior dislocation of unspecified humerus, sequela

This code signifies a long-term complication or residual effect stemming from a past posterior dislocation of the humerus, where the specific side (left or right) of the injury is not documented. It indicates that the patient is still experiencing issues directly attributable to that previous shoulder injury, such as chronic pain, instability, or limited range of motion.

Apply this code when a patient presents for treatment of ongoing problems directly resulting from a previously sustained posterior humeral dislocation, and the medical record does not specify which shoulder was affected. This would be appropriate for follow-up visits addressing chronic sequelae rather than the initial acute injury.

• Ensure documentation clearly links the current condition to a past posterior humeral dislocation.
• Only use this code when the laterality (left/right) of the humerus is truly unspecified in the medical record.
• Always sequence this sequela code after the code for the specific manifestation of the sequela (e.g., chronic pain, instability).