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Principal Illness Navigation

In November 2023, CMS released four new codes (G0023, G0024, G0140, and G0146) in the CY24 Physician Fee Schedule Final rule for Principal Health Navigation (PIN) services. PIN services are incident-to services, so they may only be offered in the non-facility setting. The final rule does include a provision that requires these patients to give informed consent prior to receiving these services. This consent may be written or verbal and should be documented in the patient’s medical record.

These codes are all time-based, and the intent is to help patients navigate the healthcare treatments for high-risk or serious illnesses, such as cancer. According to CMS, “the definition of a serious, high-risk condition is dependent on clinical judgement.” The additional characteristics offered in the description from CMS are:

  • One serious, high-risk condition expected to last at least 3 months and that places the patient at a significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death.
  • The condition requires development, monitoring, or revision of a disease-specific care plan, and may require frequent adjustment in the medication or treatment regimen, or substantial assistance from a caregiver.

Additionally, an initiating visit is required, as with other care management services. This may be an office visit billed with an E/M (other than 99211) or an AWV. The provider who performs the initiating visit and establishes the patient’s treatment plan would also be the one to report these services as incident-to. These codes may be billed incident-to a clinical psychologist, and the initiating visit may be billed using 90791, 96156, 96158, 96159, or 96164-96168.

The code descriptions are as follows:

G0023 Principal Illness Navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month, in the following activities:

G0024 – Principal Illness Navigation services, additional 30 minutes per calendar month (List separately in addition to G0023).

  • Person-centered assessment, performed to better understand the individual context of the serious, high-risk condition.
    • Conducting 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 SDOH needs (that are not separately billed).
    • Facilitating patient-driven goal setting and establishing an action plan.
    • Providing tailored support as needed to accomplish the practitioner’s treatment plan.
  • Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services.
  • Practitioner, Home, and Community-Based Care Coordination
    • Coordinating receipt of needed services from healthcare practitioners, providers, and facilities; home- and community-based service providers; and caregivers (if applicable).
    • Communication with practitioners, home-, and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.
    • Coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians; follow-up after an emergency department visit; or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
    • Facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address SDOH need(s).
  • Health education- Helping the patient contextualize health education provided by the patient’s treatment team with the patient’s individual needs, goals, preferences, and SDOH need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making.
  • Building patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services (as needed), in ways that are more likely to promote personalized and effective treatment of their condition.
  • Health care access / health system navigation.
    • Helping the patient access healthcare, including identifying appropriate practitioners or providers for clinical care, and helping secure appointments with them.
    • Providing the patient with information/resources to consider participation in clinical trials or clinical research as applicable.
  • 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.
  • Leverage knowledge of serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.

Principal Illness Navigation with Peer Support

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, in the following activities:

G0146 – Principal Illness Navigation – Peer Support, additional 30 minutes per calendar month (List separately in addition to G0140).

  • Person-centered interview, performed to better understand the individual context of the serious, high-risk condition.
    • Conducting a person-centered interview to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors, and including unmet SDOH needs (that are not billed separately).
    • Facilitating patient-driven goal setting and establishing an action plan.
    • Providing tailored support as needed to accomplish the person-centered goals in the practitioner’s treatment plan.
  • Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services.
  • Practitioner, Home, and Community-Based Care Communication
    • Assist the patient in communicating with their practitioners, home-, and community- based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient’s psychosocial strengths and needs, goals, preferences, and desired outcomes, including cultural and linguistic factors.
    • Facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address SDOH need(s).
  • Health education—Helping the patient contextualize health education provided by the patient’s treatment team with the patient’s individual needs, goals, preferences, and SDOH need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making.
  • Building patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services (as needed), in ways that are more likely to promote personalized and effective treatment of their condition.
  • Developing and proposing strategies to help meet person-centered treatment goals and supporting the patient in using chosen strategies to reach person-centered 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 person-centered diagnosis and treatment goals.
  • Leverage knowledge of serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.
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