Medial disloc of proximal end of tibia, right knee, sequela

This code signifies a chronic or late-stage complication resulting from a prior medial dislocation of the proximal tibia in the right knee. It indicates that the patient is experiencing ongoing issues directly attributable to the original injury, rather than an acute event. These sequelae can include persistent pain, instability, limited range of motion, or degenerative changes.

Apply this code when documenting a patient presenting with long-term problems or conditions that are a direct consequence of a previously sustained medial dislocation of the right proximal tibia. This would include follow-up visits for chronic pain, instability, or arthritis that developed after the initial injury has healed. It is appropriate when the original injury is no historical, and the current encounter addresses its lasting effects.

• Always ensure documentation clearly links the current condition to the prior medial tibia dislocation.
• Do not use for acute or initial injury encounters; those require acute dislocation codes.
• Consider additional codes for specific sequelae, such as chronic pain (G89.29) or osteoarthritis (M17.11), if documented.