PDPM Coding Question – Does the resident have to have a cannula in their tracheostomy to be able to code O0100E tracheostomy care?

Does the resident have to have a cannula in their tracheostomy to be able to code O0100E tracheostomy care?

A:

No, they do not. According to page 0-9 pf the RAI manual, you can “code cleansing of the tracheostomy and/or cannula in this item”, so the presence of a cannula is not required. Documentation would need to support that cleansing of the tracheostomy itself, and the cannula if present, was completed during the 14 day look back period. You can also code this if the resident performs their own tracheostomy care. This is critical to know, as coding of this item places the resident into the Extensive Services Nursing category for PDPM.