Assessment and the correct choice of V44 or V55

I recently received a great question: When your clinician is assessing a tracheostomy and ordering supplies, but the patient cares for the trach, which code is used?

As anyone who has heard me teach on V codes knows, there is a pretty easy line to draw between coding a V44 and a V55 code, but this has an interesting twist.

V44 codes are status codes, so you use them just to report the presence of a trach tube or another artificial opening. There is no clinical care involved, so you also code V44 when a patient is caring for the opening independently or with a caregiver’s help.

V55 codes are considered aftercare codes, according to the official coding guidelines, and are used when there is clinical intervention and care, such as cleaning or overall care.

Back to the question I received: We don’t have official guidance on this, but I would code the V55 code (V55.0, Attention to Tracheostomy) because only a nurse can assess the trach for infection or other issues.

Important Note: The official coding guidelines specifically say that V44 and V55 codes should not be coded together.

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