This is information from the 2024 Physician Fee Schedule Final Rule

https://public-inspection.federalregister.gov/2023-24184.pdf

CMS developed four HCPCS codes for Principal Illness Navigation. This service is intended to help patients with serious conditions navigate their health care treatment.

• PIN services are incident-to services so may only be performed in a non-facility setting
• Informed consent is required-the patient must agree to receive these services. Consent may be written or verbal, as long as it is documented in the record
• An initiating visit is required (see below)
• HCPCS codes: G0023, G0024, G0140, G0146
• The navigator may be someone who has had the disease or condition being treated

CMS defines navigation services this way.

“In the context of healthcare, it refers to providing individualized help to the patient (and caregiver, if applicable) to identify appropriate practitioners and providers for care needs and support, and access necessary care timely, especially when the landscape is complex and delaying care can be deadly.”  p. 361

CMS finalized four time-based HCPCS codes for the purpose of helping patients navigate their health care treatment for cancer and other high-risk, serious illnesses. This is to provide individualized help to the patient and caregiver to identify appropriate practitioners for care needs and support, especially when multiple specialties are involved in caring for the patient and delaying care can be deadly. CMS believes this may be most important when a patient is first undergoing treatment for a serious condition.  CMS states “…the definition of a serious, high-risk condition is dependent on clinical judgement.” p. 367.  CMS did not set a duration for PIN services.

CMS will pay for certified or trained auxiliary personnel under the direction of the billing practitioner. This may be a patient navigator or certified peer specialist as part of the treatment plan for a serious, high-risk disease which is expected to last at least three months.

Initiating visit

PIN services require an initiating visit.  When performed by a medical provider, the initiating visit (other than a low-level E/M visit that can be performed by staff, ie. 99211), can be an office visit, or Annual Wellness Visit, when a physician or NPP has performed the wellness visit.

If the PIN services are being reported by a clinical psychologist, then 90791, 96156, 96158, 96159, 96164, 96165, 96167 and 96168 may be initiating visits. Clinical psychologists have an incident to benefit. Social workers and other therapists do not have an incident to benefit, and could not bill for PIN services incident to their services.

Incident To

Physician/NPP or clinical psychologist sees the patient in a non-facility setting, establishes the plan of care and initiates PIN services that are performed by auxiliary personnel under general supervision.  PIN services may not be performed in a facility setting.

The Work

At the initiating visit, the practitioner would establish an appropriate treatment plan, and this same practitioner would report the services of the auxiliary personnel incident to their own services.

PIN services would address a serious, high-risk condition/illness/disease with the following characteristics:

• “ One serious, high-risk condition expected to last at least 3 months and that places the patient at 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.” p. 364

• Examples of serious, high-risk diseases for which patient navigation services could be reasonable and necessary could include cancer, chronic obstructive pulmonary disease, congestive heart failure, dementia, HIV/AIDS, severe mental illness, and substance use disorder (SUD).” page 362.

CMS does not believe inpatient/observation visits, ED visits and SNF visits would typically be initiating PIN services.

There are two sets of codes. G0023 and add-on code G0024 are for use by certified or trained auxiliary personnel. G0140 and add-on code G0146 are for “peer support” by certified or trained auxiliary personnel for patients with behavioral health conditions.

A practitioner may arrange to have PIN services provided under contract, such as by a community-based organization if all of the incident-to requirements are met. The  citation below reminds medical practices that this isn’t refer and forget. The third party must have clinical integration with the practice.

“Although we proposed to allow PIN services to be performed by auxiliary personnel under a contract with a third party, we clarify, as we have in our regulations for other care management services, that there must be sufficient clinical integration between the third party and the billing practitioner in order for the services to be fully provided, and the connection between the patient, auxiliary personnel, and the billing practitioner must be maintained. As we discussed in a similar context for care management services the CY 2017 PFS final rule, if there is little oversight by the billing practitioner or a lack of clinical integration between a third party providing the services and the billing practitioner, we do not believe PIN services, as we proposed to define them, could be fully performed; and therefore, in such cases, PIN services should not be billed (81 FR 80249). We would expect the auxiliary personnel performing the PIN services to communicate regularly with the billing practitioner to ensure that PIN services are appropriately documented in the medical record, and to continue to involve the billing practitioner in evaluating the continuing need for PIN services to address the serious, high-risk condition.” p 394

The HCPCS codes have lengthy descriptions, which are in common with other care management services. CMS is requiring informed consent from the patient, verbal or written, which is documented in the medical record. CMS requires that consent is documented prior to beginning other care management services. p. 394

CMS is proposing that auxiliary personnel who perform PIN services must be certified or trained to provide all included elements and be authorized to perform them under applicable state law and regulations. They say approximately 48 states have professional certification programs for peer support specialists. If the state does not have applicable licensure, certification, or other laws or regulations, CMS is proposing that axillary personnel must be trained to provide them.

Time spent performing the services must be documented in the medical record, and the work done must be documented in the medical record. Identification of SDoH needs, if present, must be noted, and for data standardization, practitioners would be encouraged to report ICD 10 codes from categories Z55—Z65. See CodingIntel’s Q&A about the definition of SDoH.

CMS notes that for peer support specialists, about 48 states have professional certifications programs for individuals providing services to patients with substance use or mental health conditions. Some states have Medicaid coverage for this and CMS has defined the minimum requirements this way:

“…peer support specialists must be self- identified consumers who are in recovery from mental illness and/or substance use disorders, supervised by a competent mental health professional, and complete training that provides peer support specialists with a basic set of competencies necessary to perform the peer support function, including demonstrating the ability to support the recovery of others from mental illness and/or substance use disorders and ongoing continual educational requirements. In States with professional certification programs, training and certification requirements vary, with an average of 40 and 46 hours of initial approved education, with almost all States requiring either a written or written and oral exam. A little less than half of States also require supervised work or volunteer hours to obtain certification.” p. 387

For states without licensure, certification or other requirements, auxiliary personnel performing these services must be trained in all service requirements.

For all four of these codes, time must be documented in the medical record. Time performing two different services may never be double counted. These services require direct contact between the auxiliary personnel and the patient, which may be in person or by phone.

Codes for Principal Illness Navigation (PIN) services

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:

CMS is proposing that auxiliary personnel who perform PIN services must be certified or trained to provide all included elements and be authorized to perform them under applicable state law and regulations. They say approximately 48 states have professional certification programs for peer support specialists. If the state does not have applicable licensure, certification, or other laws or regulations, CMS is proposing that axillary personnel must be trained to provide them.

Time spent performing the services must be documented in the medical record, and the work done must be documented in the medical record. Identification of SDoH needs, if present, must be noted, and for data standardization, practitioners would be encouraged to report ICD 10 codes from categories Z55—Z65. See CodingIntel’s Q&A about the definition of SDoH.

PIN services could be provided by employees of the medical practice, or by auxiliary personnel who are external to the practice but under contract with them. This could be through a community-based organization. CMS emphasizes however that there must be “sufficient clinical integration between the third party and the billing practitioner in order for the services to be fully provided, and the connection between the patient, auxiliary personnel, and the billing practitioner must be maintained.”

PIN services for patients with behavioral health conditions

The key difference in the two sets of codes is this: G0140 and G0141 describe the person performing the service this way, “including a certified peer specialist.” p. 385

Patients with behavioral health conditions can receive services using either codes G0023 and G0024 or the following codes. CMS says

“Given the nature of work typically performed by peer support specialists, we are limiting these codes to the treatment of behavioral health conditions that otherwise satisfy our definition of a high-risk condition(s). Patients with behavioral health conditions can still receive HCPCS code G0023 and HCPCS code G0024 services, so long as the auxiliary staff providing them is trained and certified in all parts of those code descriptors. We understand that behavioral health patients are not a monolith, and some patients may be best suited to traditional PIN services.” p. 384