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If a patient no longer has a canula, but still has the tracheostomy stoma, what is the appropriate way to code for this on the MDS?
A: Per the October 2015 RAI Manual, the coding of tracheostomy care includes the cleansing of the tracheostomy canula and/or stoma. In situations where the tracheostomy has been decannulated and all that remains is the stoma, tracheostomy care may still be coded until the area has healed, as long as this care is documented during the assessment look back period.