For the purposes of Regulation .20D(2)—(3) of this chapter, a patient with severe injury shall have:

1. A. An injury severity score (ISS) greater than or equal to 13;
2. B. A penetrating injury with systolic blood pressure of less than or equal to 90 millimeters of mercury;

3. C. A thoracic injury classified as one or more of the following International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) codes:

   1. (1) 861.21 — Lung contusion, without open wound to thorax;
   2. (2) 861.31 — Lung contusion, with open wound into thorax; or
   3. (3) 807.4 — Flail chest;

4. D. A blunt injury to the abdomen with major solid visceral injury classified as one or more of the following ICD-9-CM codes:

   1. (1) 864.03 — Moderate laceration injury to liver without mention of open wound into cavity;
   2. (2) 864.04 — Major laceration injury to liver without mention of open wound into cavity;
   3. (3) 864.13 — Moderate laceration injury to liver with open wound into cavity;
   4. (4) 864.14 — Major laceration of liver with open wound into cavity;
   5. (5) 865.03 — Injury to spleen with laceration extending into parenchyma without mention of open wound into cavity;
   6. (6) 865.04 — Injury to spleen with massive parenchymal disruption without mention of open wound into cavity;
   7. (7) 865.13 — Injury to spleen with laceration extending into parenchyma and open wound into cavity;
   8. (8) 865.14 — Injury to spleen with massive parenchymal disruption and open wound into cavity;
   9. (9) 866.01 — Hematoma of kidney without rupture of capsule or mention of open wound into cavity;
   10. (10) 866.02 — Laceration of kidney without mention of open wound into cavity;
   11. (11) 866.11 — Hematoma of kidney without rupture of capsule but with open wound into cavity; or
   12. (12) 866.12 — Laceration of kidney with open wound into cavity;

5. E. A major surgical procedure in the cranial, thoracic, vascular, abdominal, or spinal body regions, classified as one or more of the following ICD-9-CM procedure codes:

   1. (1) Cranial:

      1. (a) 01.2X — Craniotomy and craniectomy;
      2. (b) 01.3X — Incision of brain and cerebral meninges;
      3. (c) 01.52 — Hemispherectomy;
      4. (d) 01.53 — Lobectomy of brain;
      5. (e) 02.0X — Cranioplasty;
      6. (f) 02.1X — Repair of cerebral meninges;
      7. (g) 02.3 — Extracranial ventricular shunt;
      8. (h) 02.92 — Repair of brain; or
      9. (i) 02.94 — Insertion of replacement of skull tongs or halo traction device;

   2. (2) Thoracic:

      1. (a) 34.02 — Exploratory thoracotomy;
      2. (b) 34.82 — Suture of laceration of diaphragm;
      3. (c) 34.84 — Other repair of diaphragm;
      4. (d) 37.1X — Cardiotomy and pericardiotomy; or
      5. (e) 37.91 — Open chest cardiac massage;

   3. (3) Vascular:

      1. (a) 38.3 — Resection of vessel with anastomosis (use 4th digits 2, 3, 4, 5, 6, 7, 8, 9);
      2. (b) 38.4 — Resection of vessel with replacement (use 4th digits 2, 3, 4, 5, 6, 7, 8, 9);
      3. (c) 38.8 — Other surgical occlusion of vessels (use 4th digits 2, 3, 4, 5, 6, 7, 8, 9);
      4. (d) 39.3 — Suture of vessel;
      5. (e) 39.56 <MD >Repair of blood vessel with tissue patch graft;
      6. (f) 39.57 — Repair of blood vessel with synthetic patch graft;
      7. (g) 39.58 — Other repair of vessel;
      8. (h) 39.6X — Extracorporeal circulation and procedures auxiliary to heart surgery; or
      9. (i) 39.98 — Control of hemorrhage, not otherwise specified;

   4. (4) Abdominal:

      1. (a) 41.43 — Partial splenectomy;
      2. (b) 41.5 — Total splenectomy;
      3. (c) 41.95 — Repair and plastic operations on spleen;
      4. (d) 42.82 — Suture of laceration of esophagus;
      5. (e) 42.89 — Other repair of esophagus;
      6. (f) 44.61 — Suture of laceration of stomach;
      7. (g) 44.69 — Other repair of stomach, not otherwise specified;
      8. (h) 45.0X — Enterotomy;
      9. (i) 45.5X — Isolation of intestinal segment;
      10. (j) 45.6X — Other excision of small intestine;
      11. (k) 45.7X — Partial excision of large intestine;
      12. (l) 45.8 — Total intra-abdominal colectomy;
      13. (m) 46.0 through 46.03 — Other operations on intestine;
      14. (n) 46.7X — Other repair of intestine;
      15. (o) 50.0 — Hepatotomy;
      16. (p) 50.22 — Partial hepatectomy;
      17. (q) 50.3 — Lobectomy of liver;
      18. (r) 50.4 — Total hepatectomy;
      19. (s) 50.6X — Repair of liver;
      20. (t) 52.5X — Partial pancreatectomy;
      21. (u) 52.6 — Total pancreatectomy;
      22. (v) 52.95 — Other repair of the pancreas;
      23. (w) 54.11 — Exploratory laparotomy;
      24. (x) 55.4 — Partial nephrectomy;
      25. (y) 55.5X — Complete nephrectomy;
      26. (z) 55.8X — Other repair of kidney;
      27. (aa) 56.8X — Repair of ureter; or
      28. (bb) 57.8X — Other repair of urinary bladder; or

   5. (5) Spinal:

      1. (a) 03.53 — Repair of vertebral fracture;
      2. (b) 81.00 — Spinal fusion, not otherwise specified;
      3. (c) 81.01 — Atlas-axis spinal fusion;
      4. (d) 81.02 — Other cervical fusion, anterior technique;
      5. (e) 81.03 — Other cervical fusion, posterior technique;
      6. (f) 81.04 — Dorsal and dorsolumbar fusion anterior technique;
      7. (g) 81.05 — Dorsal and dorsolumbar fusion, posterior technique; or
      8. (h) 81.06 — Lumbar and lumbosacral fusion, anterior technique;

6. F. A major pelvic fracture, classified as one or more of the following ICD-9-CM codes:

   1. (1) 808.43 — Multiple, closed, pelvic fractures with disruption of pelvic circle; or
   2. (2) 808.53 — Multiple, open, pelvic fractures with disruption of pelvic circle; or

7. G. Two or more long bone lower extremity fractures that can be either ipsilateral or contralateral, classified as one or more of the following ICD-9-CM codes:

   1. (1) 820.XX — Fractures of neck of femur;
   2. (2) 821.XX — Fractures of other and unspecified parts of femur; or
   3. (3) 823.X2 — Fractures of fibula with tibia.

Authority: Education Article, §13-509, Annotated Code of Maryland

Effective date: March 24, 1997 (24:6 Md. R. 488)

Regulation .03F amended effective June 4, 2007 (34:11 Md. R. 972)

Regulation .13A amended effective July 1, 2002 (29:12 Md. R. 933)

Regulation .13F amended as an emergency provision effective June 1, 2006 (33:15 Md. R. 1277); amended permanently effective October 23, 2006 (33:21 Md. R. 1679)

Regulation .15A amended effective July 1, 2002 (29:12 Md. R. 933)

Regulation .15B amended effective June 4, 2007 (34:11 Md. R. 972)

Regulation .17A amended effective July 1, 2002 (29:12 Md. R. 933)

Regulations .20 and .21 adopted as an emergency provision effective November 7, 1997 (24:25 Md. R. 1718); adopted permanently effective March 9, 1998 (25:5 Md. R. 371)

Regulation .20 amended effective July 1, 2002 (29:12 Md. R. 933)

Regulation .20D amended effective June 4, 2007 (34:11 Md. R. 972)

Chapter revised effective July 1, 2018 (45:9 Md. R. 463)

Regulation .03C amended effective July 21, 2025 (52:14 Md. R. 714)

Regulation .13A, B amended effective April 17, 2023 (50:7 Md. R. 302)