This is information from the 2024 Physician Fee Schedule PROPOSED Rule
CMS is proposing two time-based HCPCS codes for the purpose of helping patients navigate their health care treatment for cancer and other high-risk, serious illnesses. “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. 256. CMS believes this may be most important when a patient is first undergoing treatment.
CMS is proposing to 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.
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. 259
PIN services would require an initiating E/M service, which would typically be an office visit. At this 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. CMS is proposing general supervision for PIN services.
The two proposed codes have lengthy descriptions, which are in common with other care management services. CMS is seeking comments about whether informed consent would need to be obtained before the service is provided. CMS requires that consent is documented prior to beginning other care management services. However, those other care management services are not typically performed face-to-face, and CMS wants to be sure that the beneficiary knows they’ll be receiving a bill. CMS believes most PIN services will be face-to-face, and so is not proposing to require informed consent be documented. They are seeking comments about this. (These are placeholder codes. The HCPCS codes will be released in the Final Rule in November.)
GXXX3 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:
- 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.
++ 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 caregiver (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 the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.
GXXX4 – Principal Illness Navigation services, additional 30 minutes per calendar month (List separately in addition to GXXX3).
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. In their proposed rule, 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.” p. 270
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