Wiki Sequela or Initial

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wmcodylee

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I have a case where a pt had shoulder replacement surgery 30 years ago. He now presents to our office with a partial dislocation of the same shoulder he had surgery on. He is a patient here, but this is our first time seeing him for this condition. Should I code the visit as initial encounter or sequela?
 
Unless the doctor states that the prior surgery caused the dislocation sequelae does not apply. I would use the A since you are actively treating the dislocation.
 
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