| (xxii) MRI both breasts;
(xxiii) MRI pelvis;
(xxiv) mammogram, analog;
(xxv) mammogram with CAD; and
(xxvi) mammogram, digital.
(5) Pathology services. Data on pathology services
must be reported only for professional claims for which the place
of service is an independent lab.
(A) Data must be reported at the claim-line level and
averaged to reflect the cost per unit of service.
(B) Data must be reported for the following pathology
services, using the medical billing codes consistent with §21.4505(b)
of this title:
(i) organ or disease panels;
(ii) evocative suppression testing;
(iii) urinalysis;
(iv) chemistry;
(v) hematology-coagulation;
(vi) immunology;
(vii) microbiology;
(viii) anatomic pathology;
(ix) screening cytopathology; and
(x) complete blood count.
(6) Office visits. Data on office visits must be reported
only for professional claims for which the place of service is an
office or rural health clinic.
(A) For data elements listed in subparagraph (B) of
this paragraph, data must be reported at the claim-line level and
averaged to reflect the cost per unit of service.
(B) Data must be reported for the following types of
office visits, using the medical billing codes consistent with §21.4505(b)
of this title:
(i) office or other outpatient visit with a new patient,
by time or complexity;
(ii) office or other outpatient visit with an established
patient, by time or complexity;
(iii) office consultation, by time or complexity;
(iv) preventive medicine evaluation and management,
new patient, by age group;
(v) preventive medicine evaluation and management,
established patient, by age group;
(vi) annual gynecological exam, new patient;
(vii) annual gynecological exam, established patient;
(viii) screening pelvic and breast exam;
(ix) screening pap smear; and
(x) cytopathology for pap smear.
(C) Data must be reported for well-woman exams so that
all costs associated with a claim are reported with respect to the
medical billing consistent with §21.4505(b) of this title.
(d) In reporting data required under this section,
issuers must:
(1) report data elements according to medical billing
codes specified by §21.4505(b) of this title;
(2) separately report data for insurance and HMO and
exclude any HMO claims paid through a capitation agreement;
(3) separately report data for in-network and out-of-network
claims; and
(4) filter claims data to include only:
(A) claims incurred during the 12-month reporting period.
For the 2015 reporting period, limit data for inpatient procedure
claims and outpatient procedure claims to claims incurred before October
1, 2015, or the date on which the issuer transitioned billing systems
to use ICD-10 procedure codes;
(B) claims for which adjudication is final; exclude
pending or denied claims;
(C) claims for which the issuer is the primary plan
responsible for payment; exclude claims for which issuer is the secondary
plan; and
(D) claims with an allowed amount greater than zero.
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