Welcome back to Navigation Refresh, a recurring, informative feature for novice and seasoned patient navigators alike. In this issue, we will cover updates to the Centers for Medicare & Medicaid Services (CMS) Principal Illness Navigation (PIN) codes for 2026.
CMS revised the scope of Healthcare Common Procedure Coding System (HCPCS) code G0136 so it now covers assessment of physical activity and nutrition rather than broad social risk factors. The language for Community Health Integration (CHI) codes (G0019, G0022) shifts from “social determinants of health” to “upstream drivers” that significantly limit diagnosis or treatment, allowing a broader interpretation of barriers. Mental health professionals (clinical social workers, counselors, nurses) may provide PIN and CHI services but must bill under the qualifying Medicare treating clinician; services billed must not be double billed. Implementation barriers reported include the 20% patient coinsurance, staffing/funding, role clarity, and electronic health record (EHR) documentation/time capture challenges.
In November 2023, CMS published the 2024 Medicare Physician Fee Schedule (PFS). For the first time, billing codes for patient navigation and social determinants of health (SDOH) risk assessment were included.1
The new G-codes were intended to supplement existing Current Procedural Terminology (CPT) billing codes for Chronic Care Management (CPT 99437, 99439, 99487, 99489, 99490, 99491) and Principal Care Management (CPT 99424-99427) to provide a pathway to billing for navigation activities on behalf of a Medicare beneficiary with a serious condition expected to last at least 3 months and require treatment planning and management.
A diagnosis of cancer automatically qualified a Medicare beneficiary to receive these services.
Codes G0023 and G0024 were added to the PFS to bill for the initial assessment and first 60 minutes of PIN and 30-minute increments thereafter, respectively, to compensate for person-centered assessments inclusive of social needs, care coordination, communication across and within systems, health education, and collection of health outcomes data.1
Additional codes (G0019 and G0022) for CHI were provided to conduct similar activities for individuals whose SDOH might significantly limit their ability to complete diagnosis or begin treatment for a chronic health condition.1
Finally, a code was provided for SDOH risk assessment (G0136) to be conducted not more frequently than every 6 months.1
Separate codes for peer navigation under Substance Abuse and Mental Health Services Administration (SAMHSA) standards were also provided (G0140, G0146).
PIN and CHI services are still available for billing under the original codes.2 The rate of pay varies based on adjustments each year and can be assessed using the CMS.gov PFS tool.3 Services are still eligible to be performed by auxiliary personnel appropriately trained.4 Increments for billing PIN and CHI codes have remained the same (60-minute initial charge with 30-minute incremental charges each month). Separate codes for peer navigation are also sustained.
Increments for billing PIN and CHI codes have remained the same (60-minute initial charge with 30- minute incremental charges each month). Separate codes for peer navigation are also sustained.
The biggest change effective January 1, 2026, is a change to HCPCS code G0136, previously covering SDOH risk assessments. Believing that these assessments were already included in Evaluation and Management and behavioral health codes, CMS considered deleting this code. However, after reviewing feedback from the public, CMS decided to revise the scope of the code to cover assessment of physical activity and nutrition rather than broad social risk factors. The intention of this change was to focus on the root cause of many chronic conditions and more narrowly be able to track lifestyle factors over time.
Another significant change for 2026 is the shift from “social determinants of health” to “upstream drivers” significantly limiting the ability to diagnose or treat a condition, billable under CHI codes (G0019 and G0022). Presumably, the shift in language allows for a broader interpretation of risk factors to include behavioral, structural, and environmental factors as well as social factors that could impede diagnostic resolution or treatment commencement. This may be a way to compensate for the shift in scope for G0136. Overall, this provides more leeway for what constitutes a barrier to diagnosis or treatment using the CHI codes.
The 2026 PFS further clarifies that mental health professionals conducting PIN and CHI services can bill for those services using the G-codes. In 2025, in response to questions regarding use of the codes by clinical versus nonclinically licensed navigating roles, CMS clarified that the G-codes could be used by clinical social workers as well as patient navigators, if services were not double billed. The codes were intended to supplement, not replace mental health service codes. However, billing must be “incident to” a physician visit (or nurse practitioner or physician assistant depending on state scope of practice laws). For 2026, there was additional clarification that social workers and other health professionals (mental health counselors, nurses) could use the codes for navigation activities but had to bill under the qualifying Medicare treating clinician. Mental health professionals can continue to directly bill for mental health services under appropriate CPT codes.
The Physician Payment Rule is updated each year, so following updates annually will be important. Also, implementing use of the codes remains a challenge. At the 2025 ASCO Quality Care Symposium, the Association of Cancer Care Centers (ACCC) and the Academy of Oncology Nurse & Patient Navigators presented findings from a survey of ACCC members regarding implementation of the new codes. Of this convenience sample (N=105), only 7% of respondents indicated that their practice was implementing the codes. Barriers to implementation that were reported included the 20% patient co-insurance to use the PIN and CHI codes, funding, staffing, and role clarity.5 Feedback from the field indicates additional challenges in implementing appropriate documentation in the EHR for compliance with CMS billing rules to ensure documentation of all billable activities while not double billing for services performed and billed by a team member. Specifically, creating automated and accurate documentation of time spent for billable services that is easily tallied and billed out remains an implementation challenge. More research on how to address these barriers and sharing of lessons learned during implementation are critically needed.
This edition of Navigation Refresh aligns with Standard 16 (Advocacy) of the Professional Oncology Navigation Task Force (PONT)6 and Core Competencies Domain 2: Knowledge for Practice.7
Thank you to Karline Soto, MBA, associate operating officer, Vanderbilt University Medical Center, and Amy DePaolo, LCSW, OSW-C, lead oncology social worker, Danbury Hospital – Praxair Cancer Center, for comments on a prior draft.
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