AMA CPT® Coding Update for Oncology Navigation Services and the Cancer Moonshot

To keep members informed about recent policy changes, 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. The first 2 webinars in this 4-part series provided an overview of navigation services and Principal Illness Navigation (PIN) codes. Read the previous blog post for a recap.

The third installment in Bedard’s webinar series, AMA CPT® Coding Update for Oncology Navigation Services and the Cancer Moonshot,* covers recent changes to the American Medical Association (AMA) codes and what they mean for providers. The content of this webinar, including portions of the slides presented, is summarized below.

Collaboration Among the Cancer Moonshot, CMS, and the AMA

The Cancer Moonshot and the Centers for Medicare and Medicaid Services (CMS) have worked with the AMA and other stakeholders to promote the use of and reimbursement for navigation services. The Cancer Moonshot was established in 2016 and received its initial 7 years of funding through the 21st Century Cares Act, which was signed into law in December 2016. It was later reignited in 2022 with the following goals:

• Reduce the death rate from cancer by 50% within 25 years
• Support patients with cancer, cancer survivors, and their caregivers

Cancer navigation services can further these goals by helping cancer patients and their caregivers access the appropriate clinical and supportive services, which contributes to reductions in cancer disparities and improved outcomes.

In November 2023, there were 2 important developments to support the use of and payment for navigation services. CMS finalized new reimbursement codes for cancer navigation services under Medicare and the AMA issued updated guidance on using CPT® codes for reporting and obtaining reimbursement for navigation services. The AMA codes enable providers to be reimbursed from commercial payers and thereby play an important role in promoting the use of patient navigation services.

Distinguishing Cancer Navigation Services

The AMA codes focus on clinical navigation services; these services entail clinical care, coordination, and education, and are typically provided by licensed staff or health care professionals. The new Medicare codes introduced by CMS, meanwhile, include codes to support reimbursement for services and assessments to improve access to care, such as by helping address barriers related to social determinants of health. These services are provided by various types of providers who meet standards set forth in the Medicare regulations.

Stipulations for Each Set of Codes

Three series of AMA CPT® codes can be billed when treating oncology patients: Principal Care Management, Chronic Care Management, and Complex Chronic Care Management. These codes differ by the threshold time spent with the patient, the expected duration of the illness, the type of staff engaging with the patient, and the nature of the conditions the patient must have.

* Bedard T. AMA CPT® coding update for oncology navigation services and the Cancer Moonshot. PowerPoint slideshow. August 20, 2024.

To bill for the Principal Care Management codes, there must be a serious high-risk condition and a complex chronic condition that is expected to last at least 3 months and that places the patient at significant risk of hospitalization, functional decline, or death, together with other required elements. The first 30 minutes of the patient encounter must be provided personally by a physician or a qualified health care professional per calendar month to bill the 99424 and 99425 codes. If clinical staff are providing services, the 99426 and 99427 codes would need to be billed instead, but physician time and clinical staff time cannot be combined to meet the 30-minute threshold. In addition, the codes for a physician and the codes for clinical staff cannot be billed in the same month for the same patient.

The Chronic Care Management codes are clinical staff-directed and require a 20-minute threshold of time with the patient per calendar month and 2 or more chronic conditions that are expected to last at least 12 months or until the death of the patient; they must also meet additional requirements. However, if a physician or qualified health care professional provides the services, the minimum threshold time is 30 minutes per calendar month.

The Complex Chronic Care Management codes only include clinical staff time and must meet a 60-minute threshold each month. Like the Chronic Care Management codes, there must be 2 or more chronic conditions that are expected to last at least 12 months and that also meet additional requirements.

For each set of codes, it is crucial for staff to document the services they provide for the patient and capture their time in the system throughout the month to make the billing process easier.

Low Utilization of Billing Codes

The 2022 claims data for Medicare revealed low utilization of the Principal Care Management, Chronic Care Management, and Complex Chronic Care Management codes, particularly in oncology. For Principal Care Management codes, hematology/oncology was the highest ranked oncology specialty for billing at only 3.4% and 6.5% (99424 and 99426, respectively). For the 2 Chronic Care Management codes, less than 1% of the hematology/oncology specialty billed for these services, and hematology/oncology did not bill the Complex Chronic Care Management code at all in 2022.

* Bedard T. AMA CPT® coding update for oncology navigation services and the Cancer Moonshot. PowerPoint slideshow. August 20, 2024.

There are a number of possible reasons for the low utilization of the codes. First, extensive administrative guidelines exist for documentation. In addition, in some cases providers are already performing many of the services covered by the AMA CPT® codes, and they’re being paid through patient co-pays, grants, or other means. Therefore, navigators may not be accustomed to documenting all the specific criteria these codes require. Some providers are examining the relative value of the reimbursement in light of the work involved. There is also likely a lack of understanding or awareness of all the available codes. Finally, providers may wish to avoid billing additional co-pays to their patients.

However, these care management services are important for both patients and providers. The codes enable providers to obtain reimbursement and be recognized for services many are already doing. Patient navigation services also contribute to high-quality, cohesive care with the goal of reducing health disparities. They may also result in fewer emergency department visits and hospitalizations, ultimately potentially lowering out-of-pocket costs for patients.

Steps for Implementation

One approach to implementation is to begin with a small subset of the most ill patients and to establish a core group of providers. Navigators can assist the patient throughout the care continuum, for example, by providing referrals to partners for nutrition and transportation services, among others.

Like the Principal Illness Navigation codes discussed in a previous blog, there must be an initiating visit with the physician who will bill for these services if a patient is new or hasn’t been seen in the last year. Even if the clinical staff are actually providing the care throughout the month, services are billed under the name of the physician who saw the patient. A comprehensive evaluation/management, an annual wellness visit, or a preventive physical exam can all serve as the initiating visit. At this time, the physician must discuss the care management services with the patient and document verbal or written patient consent in the medical record.

Specifically, the patient consent must include the following information:*

• The availability of care management services
• The patient’s possible cost-sharing responsibilities
• That only 1 practitioner can provide and bill care management services during a calendar month
• The patient’s right to stop care management services at any time (effective at the end of the calendar month)
• That the practitioner explained the required information and an indication of whether the patient accepted or declined services

It is very important to document patient consent, as it is needed in order for providers to bill for these navigation and care management services.

These regulations, codes, and initiatives of CMS, the AMA, and the Cancer Moonshot seek to expand the availability of navigation and care management services. The overarching goal of these efforts is to improve the quality and equity of care provided to patients with serious illnesses, including cancer, in a lasting way.

Access the presentation slides and webinar recordings for the full Implementing the New CMS Reimbursement Billing Codes for Patient Navigation Services here, and read the previous blog in this series on the ACCCBuzz Blog.

References:

* Bedard T. AMA CPT® coding update for oncology navigation services and the Cancer Moonshot. PowerPoint slideshow. August 20, 2024.  https://www.accc-cancer.org/docs/documents/advocacy/billing-and-coding/accc-ama-cpt-coding-update-for-oncology-navigation-services-and-the-cancer-moonshot.pdf?sfvrsn=df0ff54a_2&utm_medium=email&utm_source=Act-On+Software&utm_campaign=Ed%20-%20FAN.