Patient presents as trach-dependent, requiring a tracheostomy tube for ventilation.  The tracheostomy dependence is due to [clearly documented underlying medical condition, e.g., prolonged intubation, neuromuscular disorder, upper airway obstruction, congenital anomaly].  Current tracheostomy tube size is [size] [inner cannula details, e.g., with/without fenestration, cuff type].  Respiratory status is monitored via continuous pulse oximetry and intermittent arterial blood gas analysis.  Patient exhibits [describe secretions, e.g., thick, thin, copious, scant] tracheal secretions requiring [frequency] suctioning.  Tracheostomy care is provided [frequency] using sterile technique, including cleaning of the stoma site and changing of tracheostomy dressings.  Patient tolerates tracheostomy care well.  Current respiratory support settings are [specify ventilator settings if applicable, e.g., FiO2, tidal volume, respiratory rate, PEEP].  Assessment includes evaluation of stoma site for signs of infection, granulation tissue, or skin breakdown.  Patient and or caregiver are instructed on tracheostomy care, suctioning techniques, and emergency procedures.  Plan includes continued respiratory support, ongoing tracheostomy care, pulmonary hygiene, and monitoring for complications such as tracheal stenosis, infection, or bleeding.  Referral to speech therapy for evaluation of swallowing function and potential for decannulation will be considered when clinically appropriate.  Diagnosis: Tracheostomy dependence (V44.0).  Associated diagnoses include [list associated diagnoses].  ICD-10 code: Z99.11 (Dependence on respirator).  CPT codes for tracheostomy care and suctioning will be billed according to the services provided.