Research shows that patient navigation is an effective service designed to help manage the complexities of a serious illness like a cancer diagnosis or a chronic disease.1 While advancements in cancer therapy improve patient survival, they also heighten the risk of overlooking important steps in the treatment process. Underserved populations with limited resources are placed at greater risk for poor outcomes. Due to the complexities of navigating cancer treatments, patients can experience care delays or missed opportunities, such as clinical trials and complementary and alternative medicine services,2 which can help with symptom management in cancer care. Addressing these difficulties makes the role of a navigator vital to improved outcomes, patient access, and patient satisfaction.
RWJBarnabas Health and Rutgers Cancer Institute is the largest healthcare system in New Jersey. We serve a diverse population, and our facilities range from a National Cancer Institute–designated comprehensive cancer center to smaller community cancer centers. Seven of the facilities are considered safety-net hospitals. Our navigation program began in 2019 with a handful of nurse navigators. With the funding support of the oncology service line, it has grown to include 41 disease-specific and multisite clinical nurse navigators and 26 patient access and patient care navigators. We navigate approximately 11,000 oncology patients each year using a longitudinal model of care.
Traditionally, funding for navigation programs comes from the organization’s operations budget or from grant funding, making the navigator position unstable, especially in the most vulnerable communities already relying on limited resources to provide care. In January 2024, the Centers for Medicare & Medicaid Services (CMS) finalized a payment rule to advance health equity and support the unique expertise of a navigator.3,4 The rule under the 2024 Medicare Physician Fee Schedule includes provisions for payment using G codes (G0023, G0024) for principal illness navigation (PIN) services to those experiencing a serious illness, such as a cancer diagnosis, expected to last at least 3 months. Many healthcare organizations, especially those in communities with low economic status, paused implementation worried that patient’s cost-sharing would add to the current financial burden created by some of the innovative advanced cancer treatments.
As exciting as the opportunity to bill for the service is, drilling into the terminology, the required CMS guidelines, and changing the culture of the navigator to a fee-for-services was not simple.
As exciting as the opportunity to bill for the service is, drilling into the terminology, the required CMS guidelines, and changing the culture of the navigator to a fee-for-services was not simple. In many programs, including mine, navigation begins at or near a confirmed cancer diagnosis, with many hours spent addressing access to care and removing the obstacles that could prevent or delay the first visit to the oncologist. However, under the CMS ruling, billing begins with the initial physician consultation and can continue throughout the disease process beginning with a 60-minute initial coding (G0023) followed by 30-minute increments (G0024).
Breaking down the required billing tasks was multifaceted. Unraveling the timing of charges and how and where you can charge required stakeholders from revenue integrity, health information management (HIM), patient accounts, decision support, providers, and electronic health record (EHR) builders. Each stakeholder holds a critical piece to reaching the first navigation bill.
Revenue integrity provided insight into organizational internal controls, processes, and accurate compliance with the ruling. HIM and patient accounts guided the accuracy, accessibility, and protection of the patient health information and expected patient impact. CMS requires a provider referral to navigation services.4 Having physician champions added support to the adoption and dissemination throughout the organization. In 2019, the navigation program adopted standardized metrics using the Academy of Oncology Nurse & Patient Navigators (AONN+) Metrics Study,5 including time spent with the patient, time spent on tasks, guidance for continuity of care, and addressing patient barriers. Streamlining the path to navigation as the organization moved to a single EHR, an internal referral process was developed for all facilities. Enhancements to the navigator’s template included adding a field by the EHR builder to confirm the patient’s understanding of navigation and agreement to use the service.
The CMS components include validating the skills of the navigator through training. Multiple organizations offer resources to meet the training requirement, including GW Oncology Patient Navigator Training: The Fundamentals, American Cancer Society LION, National Consortium of Breast Centers, and AONN+.6 RWJ Navigation orientation includes using the GW Fundamentals for every navigator. Other components for charging include an indication for navigation, such as a condition lasting more than 3 months; a referral from the treating provider; patient consent for navigation services; a person-centered assessment; and resources to remove obstacles.
The new CMS requirements for PIN billing aided in changing the culture of navigation. The Oncology Navigation Standards of Professional Practice include that oncology navigators should obtain the necessary education, licensure, and/or certification for their position; be knowledgeable of current practice; and be part of interdisciplinary and interorganizational collaboration vital to support patient adherence.7 Navigators’ use of the PIN codes for billing validates their professional standards and unique skills.
Charging for navigation services in oncology is a complex process that requires determination and perseverance to target potential revenue sources while shifting the cost for navigation out of the operational budget. All stakeholders must contribute their unique expertise to guide the effort and ensure compliance with CMS and, potentially, additional state regulations.
The challenges include defining the necessary documentation to validate charges, creating templates in the EHR, and developing the automation to streamline the charging process.
The challenges include defining the necessary documentation to validate charges, creating templates in the EHR, and developing the automation to streamline the charging process. Most importantly, it is crucial to recognize the need to provide patient-centered care, identify barriers, and increase access to timely cancer services and support for better outcomes and health equity.
The complete impact of using the new codes for navigation has yet to be determined. While billing has monetary value and could, in time, prove useful in increasing resources, I believe the greatest value is seeing the navigator’s role and expertise validated and demonstrating the professional standards of the position.
“No person with cancer should have to spend more time fighting their way through the cancer care system than fighting their disease.” —Harold P. Freeman, MD, Honorary Chair of the National Navigation Roundtable
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