A patient comes in post anoxic brain injury chronic trach/peg for sepsis . Upon entering the ER, it is stated the tracheostomy looks discolored. The family states it's been over a year since the tracheostomy has been changed due to the inability to remove it. Shortly after admission, the patient develops respiratory failure. The tracheostomy could not be used due to not being able to ventilate/oxygenate the patient. After several attempts of trying to replace the trach at bedside, the trach was removed, and the patient was orally intubated. Four days later, the patient was brought to the OR for a tracheostomy creation. In the physicians Op note, the prior tracheostomy site was closed with granulation tissue, but he was able to find a sinus that traveled deeply. He then punctured this granulation tissue and mucous membrane to sequentially dilate the sinus tract. He was now able to advance the tracheostomy into the trachea after the ET was withdrawn. I'm new to this CDI position, and I can't seem to find a PCS code to appropriately match this patient's situation. Change, revision, and repair do not seem to fit the picture since the mucous membrane was punctured. The previous device was completely taken out for four days before placing a new tracheostomy. I appreciate your help and time on this matter.