Breaking Down Principal Illness Navigation Services: Helping Oncology Providers and Administrators Document, Code, and Bill for Patient Navigation Services

The Association of Cancer Care Centers (ACCC) recently hosted the webinar series, Implementing the New CMS Reimbursement Billing Codes for Patient Navigation Services, led by Teri Bedard, BA, RT(R)(T)(ARRT), CPC, of Revenue Cycle Coding Strategies, to inform members about the recent policy changes and what they mean for providers. In implementing the new codes, the Centers for Medicare & Medicaid Services (CMS) seeks to enhance the availability of patient navigation services and in turn improve equitable access to cancer care and other types of health care services.

The first webinar was held in July of 2024; it provided a high-level overview of the new Medicare and American Medical Association (AMA) billing codes, previewing the topics to be addressed in subsequent webinars. In the second webinar, held in August of 2024, Bedard focused on the new Medicare Principal Illness Navigation (PIN) codes and the Peer Support Principal Illness Navigation (PIN-PS) reimbursement codes, which went into effect in 2024. These latter codes are specific to mental health and behavioral health services and require distinct certifications, training, and expertise.

Rationale for the New Codes

CMS recognized that providers were not getting paid for all the services they provide to help patients navigate the health care system. The new codes are intended to account for the additional resources and time providers take to care for patients with serious illnesses and to remove or reduce health-related social barriers that may interfere with the implementation of the care plan. They consider how the social determinants of health may impact diagnosis and treatment, or even the patient’s ability to be physically present for treatment.

“When we think of our patients, it’s not a one-and-done service,” noted Bedard. “They may be coming back weekly or even daily, and that can have an impact on them.”

The Important Role Navigators Play in Cancer Care

Medicare defines navigation as the provision of “individualized help to the patient to identify appropriate practitioners and providers for care needs and support, and access necessary care” in a timely fashion, according to Bedard.

• Types of staff: The new PIN codes recognize the oncologist, who provides an initial visit, handles the ongoing management of the patient, determines the patient plan, and bills for services provided. They also recognize the auxiliary staff, typically the nurse navigator or social worker, who work under the direction of the oncologist to carry out the patient plan.
  
• Required training: Medicare’s standard PIN codes, G0023 and G0024, do not require a set number of training hours, but instead look to state requirements. In the absence of state requirements, Medicare expects basic competency training in patient and caregiver communication, patient advocacy, and specific certification relative to the high-risk condition being addressed.

New Code Requirements

Required visits for PIN codes: The PIN codes G0140 and G0146 require an initiating visit with the physician that addresses a serious, high-risk condition. This is followed by continued monthly visits with the auxiliary staff as needed. Inpatient observation, emergency department (ED) visits, and skilled nursing visits are excluded from the PIN codes.

• Eligible conditions: The patient must have 1 serious high-risk condition expected to last at least 3 months that places them at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death. These may include cancer, chronic obstructive pulmonary disease, HIV/AIDS, mental illness, and any of many other conditions.
• Treatment plan and time tracking: The condition must require development, monitoring, or revision of a disease-specific care plan, and it may require frequent adjustment of the medication or treatment regimen. The G0023 and G0024 codes are also time-based; auxiliary staff must spend at least 60 minutes with patients per calendar month. Therefore, tracking time spent with patients is very important for reimbursement.

Beneficiaries can receive more than 1 PIN service at a time as long as the services are not for the same condition or furnished by the same practitioner.

Required visits for PIN-PS codes: The PIN-PS codes also require that the initiating visit address a serious, high-risk condition, along with ongoing, continued visits throughout the month. Inpatient observation and ED visits are also excluded.

• Eligible conditions: The PIN-PS codes help to identify the appropriate practitioners and treatment for behavioral health conditions.
• Required training: There is slightly different training expected for the PIN-PS personnel. They still must adhere to state regulations regarding certification or licensure. However, if their state has no specific guidelines relating to peer support, they must be trained using the National Model Standards for Peer Support certification published by the Substance Abuse Mental Health Services Administration.
• Treatment and time tracking: Staff are required to spend and document 60 minutes with the patient per month.

The Initial Visit

The practitioner must perform an evaluation management visit if the patient is new or has not been seen by that practitioner in the last year. Unlike for a regular visit, the physician must discuss the care management services with the patient, and patient consent must be documented.

The disease-specific care plan must include:

• Problem list
• Expected outcomes and prognosis
• Measurable treatment goals
• Symptom management/interventions
• Medication management
• Any ordered specific services
• Description of how services by outside organizations will be coordinated and managed in support of the care plan.

A Better Understanding of Patient Needs Leads to Improved Outcomes

The new codes emphasize the importance of conducting a patient-centered assessment. They reimburse providers for time spent to better understand the individual context of the serious high-risk condition and the patient’s life story, strengths, and goals. This can bolster patient investment in the treatment plan and promote successful outcomes for the care and treatment regimen. The codes also reimburse for time spent teaching patients self-advocacy skills to ensure that patients understand their treatment and can navigate the health care system with confidence. In addition, the PIN codes address social and emotional support services. Time spent finding ways to help patients cope with their condition, adjust their daily routine to better meet their diagnosis and treatment goals, and manage their social determinants of health should therefore all be tracked and billed.

PIN codes also require verbal or written patient consent documented in the medical record and obtained annually. This step ensures that patients understand they will be financially responsible for a co-pay involving patient navigation services.

This blog is the first in a 3-part series that deep dives into the new navigation codes in Medicare. Stay tuned for Part 2 and Part 3 on the ACCCBuzz Blog.