Oncology & Hematology Coding Alert

And see how they compare with principal care management.

When the Centers for Medicare & Medicaid Services (CMS) finalized the Physician Fee Schedule (PFS) for 2024 in November 2023, they introduced four new HCPCS Level II codes for documenting principal illness navigation (PIN) services. The codes, created as a direct response to President Biden’s “goal of making cancer-navigation services — services that help guide individuals, caregivers, and families through cancer screening, diagnosis, treatment, and survivorship — a covered benefit for Americans facing cancer” (https://www.ama-assn.org/ system/files/cpt-assistant-oncology-navigation-codes.pdf), became effective on Jan. 1, 2024.

Here’s what you need to know to implement them, and how to use them in conjunction with the principal care management (PCM) codes CPT^® introduced in 2022. But first, in order to understand how to use the new codes correctly, it’s important to understand what oncology navigation entails.

Understand Oncology Navigation

According to the Professional Oncology Navigation Task Force, oncology navigation refers to the “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience” (https://www.ons.org/sites/ default/files/2023-06/Patient Navigation Standards _ WebViewer.pdf). In short, “PIN services are designed to help patients identify and connect with appropriate clinical and support resources,” according to the November 2023 Special Edition of CPT^® Assistant (https://www.ama-assn.org/system/files/cpt-assistant-oncology-navigation-codes.pdf).

Review the New Codes and What They Report

The 2024 PFS introduced the following four codes:

• G0023 (Principal illness navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator; 60 minutes per calendar month …) with its add-on +G0024 (… additional 30 minutes per calendar month (list separately in addition to G0023))
• G0140 (Principal illness navigation - peer support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month …) with its add-on +G0146 (… peer support, additional 30 minutes per calendar month (list separately in addition to G0140)).

According to CPT^® Assistant, G0023 and G0024 describe PIN services “provided by certified or trained auxiliary personnel under the direction of a physician or other practitioner: these personnel may include a patient navigator or certified peer specialist,” while G0145 and G0146 “were created specifically to describe PIN services provided by peer support (PS) specialists around behavioral health conditions.”

Spot the Differences Between PCM and PIN

PIN services look similar to the PCM service codes that CPT^® introduced in 2022:

• 99424 (Principal care management services, for a single high-risk disease: … first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month) with its add-on +99425 (… each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month …)
• 99426 (Principal care management services … first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month) with its add-on +99427 (… each additional 30 minutes of clinical staff time directed by a physician or other qualified health care profes­sional, per calendar month …).

In fact, while PCM and PIN both describe a type of illness navigation, the two code sets differ a great deal based on the care navigation and provider type, as the following table shows:

These differences are also reflected in the full descriptors of the codes. PCM, for example, must include clinical responsibilities, such as “adjustments in the medication regimen,” and “ongoing communication and care coordination between relevant practitioners furnishing care.”

PIN, on the other hand, comprises a larger number of activities, including, but not limited to, the following as detailed by the descriptors for G0023/+G0024 and G0140/+G0146:

• A person-centered assessment to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors and including unmet social determinant of health (SDoH) needs (that are not separately billed)
• Coordinating receipt of needed services from healthcare practitioners, providers, and facilities; home- and community-based service providers; and caregiver (if applicable)
• Communication with practitioners, home- and community-based service providers, hospitals, and skilled nursing facilities (or other healthcare facilities)
• Follow-up after discharges from hospitals, skilled nursing facilities, or other healthcare facilities
• Facilitating access to community-based social services (e.g., housing, utilities, transportation, likely to promote personalized and effective treatment of their condition
• Helping the patient access healthcare, including identifying appropriate practitioners or providers for clinical care, and helping secure appointments with them
• 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
• 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
• Leverage knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals

The difference: “PCM assists the patient to manage their health condition clinically with integrated input and clinical support from healthcare providers and clinical staff. PIN requires certification, but not clinical training, to help patients navigate their healthcare and support and improve their success as they recover,” says Kelly Loya, CPC, CHC, CPhT, CRMA, CHIAP, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, Charlotte, North Carolina.