Medicaid SSI Criteria. The member had an inpatient stay for a minimum of four days or an inpatient stay less than four days length if the member died while on total respiratory support. The SSI member must have one of the following qualifying LTC or APR-DRG codes. APR DRG codes require a supporting ICD- Procedure Codes: MS-DRG Description APR DRG ICD PROC Description 870 Septicemia or Severe Sepsis w MV 96+ Hours 720 5A1955Z Septicemia & Disseminated Infections and; Respiratory Ventilation, Greater than 96 Consecutive Hours 927 Extensive third degree burn with skin graft with; 5A1955Z (Respiratory ventilation, Greater than 96 consecutive hours) 841 5A1955Z Extensive 3rd degree xxxxx w skin graft; Respiratory Ventilation, Greater than 96 Consecutive Hours 933 Extensive third degree burn without skin graft with; 5A1955Z (Respiratory ventilation, Greater than 96 Consecutive hours) 843 5A1955Z Extensive 3rd degree or full thickness xxxxx w/o skin graft Respiratory Ventilation, Greater than 96 Consecutive Hours 003 Tracheostomy with mechanical ventilation 96+ hours or principle diagnosis except xxxx, xxxx, and mouth diagnosis with major OR procedure 004 N/A Tracheostomy w MV 96+ hours w extensive procedure or ECMO 004 Tracheostomy with mechanical ventilation 96+ hours or principle diagnosis except xxxx, xxxx, and mouth diagnosis without major OR procedure 005 N/A Tracheostomy w MV 96+ hours w/o extensive procedure 207 Respiratory system diagnosis with ventilator support 96+ hours. 130 N/A Respiratory system diagnosis w ventilator support 96+ hours If an SSI member is removed from the ventilator to be transferred to home or a hospice/skilled nursing facility prior to the four day ventilator requirement and he/she dies within 48 hours of the transfer, the Department will pay all Medicaid covered services to the end of the month or the member’s date of death, whichever comes first. This applies to a member being removed from the ventilator in 2016 or after. The need for total respiratory support must be documented by a copy of the UB-04 or a copy equivalent to the UB-04 with at least one of the LTC or APR-DRG codes (with the designated ICD-10-PCS procedure code) listed above or a copy of the member’s admission history and physical exam, discharge summary, physician and nurse’s notes that pertain to the member’s ventilator use. If a member is transferred to home or a hospice/skilled nursing facility the Department will need medical documentation that includes the member’s date of death a...
