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SSI Adults Ambulatory Care

VBP Disabled (SSI) Adults aged 21-64 years old.

Disabled (SSI) Adults aged 21-64 years as of December 31 of the measurement year who meet all of the following criteria during the calendar year:

  • Enrolled in a disabled coverage group for 320 or more days.
  • Enrolled in a single HealthChoice MCO for 320 or more days.
  • Enrolled in the HealthChoice MCO as of December 31 of the measurement year.
  • Had no more than one gap in enrollment of up to 45 days during the measurement year.
  • Enrolled in a disabled coverage group on December 31 of the measurement year.

The disabled coverage groups include the following eligibility categories:

  • S01: Public Assistance to Adults
  • S02: SSI Recipients
  • S98: ABD – Medically Needy
  • H01: HCBS Waiver and PACE participants
  • A04: Disabled adults, no Medicare, up to 77% FPL

Best Practice and Measure Tips

This measure excludes

  • Inpatient admissions and emergency department services.

This measure includes

  • Ambulatory care visits with a behavioral health diagnosis code (mental or chemical dependency), if those visits were covered by the MCO.
  • At least one ambulatory care visit in an office or any PCP outpatient visit. Preventative well visits preferred.

Documentation via claims

  • This is a Maryland Department of Health (MDH) custom measure and reporting is captured by billing and encounter codes only.

Measure Codes

  • Urgent care center visit
    • S9083, S9088
  • Preferred Codes - preventive medicine CPT codes associated with this measure are contained in the following value sets:
  • Telephone Visits Value Set: CPT 98966-98968, 99441-99443.
  • Telephone Visits Modifiers: GT, 95:
  • GT: Via interactive audio and video telecommunication system.
  • 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.
  • Telehealth Place of Service (POS) 02.
  • E-visit or virtual check-in (Online Assessments Value Set): 98969-98972, 99421-99444, 99457, G0071, G2010, G2012, G2061-G2063
  • Outpatient visit (Outpatient Value Set): CPT: 99201-99205, 99211-99215, 99241-99245, 99341-99350, 99381-99385, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483 G0402, G0438, G0439, G0463, T1015**.
  • Ambulatory outpatient visit: 92002, 92004, 92012, 92014, 99201-99205, 99211-99215, 99241-99245, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337, 99341-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99461, 99483, G0463, T1015**.
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)