The significance of billing for navigation services was a topic of discussion at the 2024 Academy of Oncology Nurse and Patient Navigators (AONN) Midyear Conference. Presenter Danielle Brown, MBA, BSN, RN, OCN, CN-BN, described the importance of billing for navigation services and provided examples.
She stated, “We have about 90 to 100 community practices across the state of Florida, and a large group of nurses were using the Oncology Care Model (OCM) to offer navigation services. There were some reimbursements coming through the Monthly Enhanced Oncology Services (MEOS) payments through that model. When the OCM ended, it led to a loss of revenue for many practices across the nation.”
Nevertheless, despite the lack of revenue, there remained an excess of nurses offering navigation services, as providing guidance to patients is of utmost importance. “Continuing navigation is the right thing to do whether or not there is reimbursement; it is the right thing to do for our patients,” she said.
In response to this loss of revenue, nurse assignments shifted, and there was a refocus of efforts after the OCM ended. This example highlights the significance of invoicing for navigation services. It is also crucial to bill for navigation to offset the expenses of employing full-time staff, investing in technology upgrades, and supporting value-based healthcare.
Background on Navigation Services
The OCM functioned as a risk model that accounted for upside risks only. The additional MEOS totaled approximately $160 per beneficiary each month. Nearly all cancer types were included in the OCM, and it did not require a collection of sociodemographic data. When the OCM ended, practices had the option to utilize the newer Enhancing Oncology Model (EOM). The EOM required electronic patient-reported outcomes and a social needs screening tool. The MEOS are more affordable with this model and cost about $70 per beneficiary per month. An alternative to EOM is Principal Illness Navigation (PIN) services, which requires patient consent. Before PIN services can start the billing process, the practitioner must perform an initiating visit, and a treatment plan must be completed for the patient. Documentation in electronic medical records (EMRs) must include the following: time spent providing PIN, activities performed by auxiliary personnel, how activities are related to the treatment plan, and social determinants of health (SDOH) needs, if present. The purpose of PIN services is to assist Medicare enrollees with high-risk conditions in identifying and connecting with clinical and support services. Ms Brown described some challenges she faced with utilizing the new PIN services.
"There have been some challenges and, like I said, I’m learning this with all of you, and there’s a lot of nervousness of being like the first to try to do something, but I want to help everybody, and we’ll learn lessons along the way. Internally, my practice wasn’t sure if this is something we could do because of being MIPS [Merit-based Incentive Payment System] participants, which is a market incentive program, but they said we couldn’t do chronic care management or principal care management because we are in a different kind of agreement,” she said.
She experienced initial internal pushback around the MIPS requirements, challenges with trying to build EMR documentation requirements into her team’s existing healthcare system, the need to hit 60 minutes with the patient before using the code G0023, obtaining patient consent, cost-sharing, staffing, and the manual billing process.
Nicole Centers, MBA, BSN, RN, OCN, CBCN, CN-BN, described some of the challenges her team faced. She said, “When we look at the G codes, one of the main sticking points for our compliance department was that it’s incident to our physician services. What this means is we have to get our chiefs or our physician leaders on board to support this.”
PIN CPT Codes for Reimbursement and PIN Billing Requirements,
The PIN Current Procedural Terminology (CPT) billing G codes are new for 2024 and only applicable to Medicare patients; other insurers that are now reimbursing for navigation services may use different codes. To use these codes, patients must meet requirements for out-of-pocket expenses. These new codes include the CPT code G0023 (PIN services, 60 minutes per calendar month), G0024 (PIN services, additional 30 minutes per calendar month), and other codes for comprehensive care and specialized support.
There are billing requirements for utilizing PIN services. The Centers for Medicare & Medicaid Services (CMS) requires that “auxiliary personnel must meet any applicable requirements to provide incident to services, including licensure or other requirements, which are required by the state in which the services are being furnished. In states that do not have applicable licensure, certification, or other laws or regulations governing the certification or training of auxiliary personnel, staff performing PIN services must be trained in the competencies of and authorized to perform the following service elements: patient and family communication, interpersonal and relationship-building, professionalism and ethical conduct, patient and family capacity-building, service coordination and system navigation, patient advocacy and facilitation of care, individual assessment, community assessment and referral information, development of an appropriate knowledge base, and document appropriately.” CMS does not emphasize particular training or certification programs that are mandatory, nor does it outline the documentation criteria that practices need to uphold to confirm the completion of a certification or training program.
The documentation requirements for services include length of time spent on navigation services; document consent; identify patient and either do an assessment or address a portion of the assessment (How are you working on barrier removal?); referrals given for patient or caregiver; document receipt of care and participation in it; health education specifically regarding diagnosis referred to navigation; building patient self-advocacy skills, so that the patient can interact with members of the healthcare team and related community-based services in ways that are more likely to promote personalized and effective treatment of their condition; healthcare access/health system navigation; facilitating behavioral change as necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach person-centered diagnosis or treatment goals; facilitating and providing social and emotional support to help the patient cope with the condition, SDOH need(s), and adjust daily routines to better meet diagnosis and treatment goals; and may share a lived experience to provide support, mentorship, or inspiration to meet treatment goals (must document relevance).
Billing for navigation services was emphasized as crucial at the conference, with Ms Brown stressing the vital importance of invoicing for these services in light of recent reimbursement obstacles. Following the conclusion of the OCM, which previously compensated nurses providing navigation services, practices nationwide faced revenue loss and had to adapt nurse assignments accordingly. Despite these financial setbacks, the demand for navigation services remains high due to their pivotal role in patient care and support. Ms Brown underscored that billing for navigation services not only offsets costs related to staffing and technology but also supports the shift toward value-based healthcare. The introduction of new billing codes for PIN services under Medicare further underscores the evolving landscape and the necessity for compliant documentation and billing practices to ensure sustained support for patients navigating complex healthcare systems.