Tracheostomy status

This code indicates that a patient currently has a tracheostomy, which is a surgically created opening in the trachea (windpipe) to facilitate breathing. It signifies the presence of the stoma and/or the tracheostomy tube itself, providing an alternative airway.

Use this code when documenting a patient's current status of having a tracheostomy, regardless of the reason for its placement. This applies to both inpatient and outpatient settings when the tracheostomy is an ongoing condition impacting care or is being managed. It is often used in conjunction with codes for the underlying condition necessitating the tracheostomy.

• Always sequence this code as a secondary diagnosis, following the code for the underlying condition that required the tracheostomy.
• Do not use this code for a history of tracheostomy if the stoma has been permanently closed.
• Ensure documentation clearly indicates the ongoing presence of the tracheostomy.