J95.02
BillableInfection of tracheostomy stoma
HCC Category Mapping
V28HCC 211 — Respirator Dependence/Tracheostomy Status/Complications
0.450V24HCC 82 — Respirator Dependence/Tracheostomy Status
1.241ESRDHCC 82 — Respirator Dependence/Tracheostomy Status
0.000What This Code Means
An infection or inflammation at the site where the tracheostomy tube enters the windpipe.
Coding Tips
- •Document the causative organism if identified through culture or testing
- •Consider if this is a superficial stoma infection or deeper tissue infection for clinical accuracy
Clinical Significance
Infection of tracheostomy stoma is a common complication where bacterial colonization progresses to active infection at the surgical opening. This can range from superficial cellulitis to deep tissue infection with potential for mediastinitis or sepsis. Tracheostomy infections increase length of stay, antibiotic requirements, and can compromise airway management.
Documentation Requirements
- ✓Documentation of infection signs at the tracheostomy stoma (erythema, warmth, purulent drainage, induration)
- ✓Culture results from the stoma site identifying the causative organism
- ✓Depth of infection assessment (superficial cellulitis vs. deep tissue infection vs. necrotizing infection)
- ✓Antibiotic regimen prescribed and duration
- ✓Assessment of tracheostomy tube integrity and whether tube change is needed
Use Additional Code
Commonly Confused Codes
J95.00 — Unspecified tracheostomy complication is less specific when infection is clearly documentedJ95.01 — Hemorrhage from tracheostomy stoma is a different complication that may co-occur with infectionL08.9 — Local infection of the skin and subcutaneous tissue unspecified is for non-tracheostomy skin infectionsT81.49XA — Infection following a procedure of other part of respiratory system may overlap but J95.02 is more specific