Infection of tracheostomy stoma

This code signifies an infection occurring at the surgical opening (stoma) created in the trachea for a tracheostomy tube. It indicates the presence of an inflammatory response, often bacterial, at the site where the tracheostomy tube enters the airway. This can manifest as redness, swelling, purulent discharge, or pain around the stoma.

Use this code when documentation clearly indicates an infection localized to the tracheostomy stoma. This typically includes findings such as erythema, tenderness, purulent drainage, or cellulitis specifically at the stoma site. Supporting documentation would include physician notes detailing the signs and symptoms of infection and its direct association with the tracheostomy stoma.

• Do not use this code for a generalized tracheobronchitis or pneumonia, even if the patient has a tracheostomy; the infection must be localized to the stoma.
• Always code the specific infectious organism (e.g., B95-B97) as an additional diagnosis, if identified and documented.
• Consider sequencing this code after the primary reason for the tracheostomy if the infection is a complication of the procedure or device.