By Erica Fischer-Cartlidge, DNP, RN, AOCNS®, EBP(CH), and Emily L. Graham, MSHIM, RHIA, CCS-P
Patient navigation has the potential to improve patient satisfaction, reduce health disparities, and ultimately optimize cancer outcomes. However, navigation services are often funded externally through grants or considered unreimbursed administrative costs because of lack of reimbursement. In January 2024, the Centers for Medicare and Medicaid Services (CMS) established its first coding and payment for principal illness navigation (PIN) services. CMS said that funding the services would improve health equity in patients with serious, high-risk conditions such as cancer.
PIN Rule at a Glance
CMS defines PIN as a service for serious, high-risk conditions with a duration of at least three months that place patients at increased risk for hospitalization, nursing home placement, acute exacerbation or decompensation, functional decline, or death. PIN-appropriate conditions may also require monitoring or updating of a care plan, treatment or medication adjustments, or a caregiver’s support. CMS lists cancer among its examples of a serious, high-risk condition.
To bill for the services, a provider must complete an initiating visit that establishes the need for PIN. The initiating visit is billed separately from other PIN services and is a prerequisite for billing any subsequent PIN services. Only providers who can complete the initiating visit may bill for PIN services, not the navigator.
Requirements for Navigators
The CMS rule for PIN also outlines requirements for those providing navigation. CMS specifies that individuals providing navigation must meet their applicable state requirements, including certification or licensure. In states with no applicable requirements, PIN service providers must be trained or certified in:
- Patient and family communication
- Interpersonal and relationship-building
- Patient and family capacity building
- Service coordination and systems navigation
- Patient advocacy, facilitation, and individual and community assessment
- Professionalism and ethical conduct
- An appropriate knowledge base, including certification or training on the serious, high-risk condition being addressed
Many, if not all, of the competency requirements are standard components of nursing education programs. Further, the Oncology Certified Nurse (OCN®) and Certified Breast Care Nurse (CBCN®) certifications offered by the Oncology Nursing Certification Corporation address and validate a nurse’s knowledge of the required competencies.
Although not expressly stated, the CMS rule’s language largely skews toward nonclinical navigators, which leaves questions for nurses providing navigation services.
How a navigator should document training is also not expressly clear in the rule. ONS recommends that nurses should document their licensure and any additional navigation-specific education with their organizations and is working with CMS to clarify the unique nursing questions.
What Oncology Nurses Need to Know
Under the new rule and the increasing demand for PIN, oncology nurses may work more often with nonclinical navigators in supporting patients with cancer. Many programs may have or be developing a model that includes clinical and nonclinical navigators. To optimize collaboration, all oncology nurses should be familiar with the delineations between the two roles as outlined in ONS’s Oncology Navigation Standards of Professional Practice.
ONS’s nurse navigation resources (see sidebar) are continually updated with the most current evidence. For example, ONS volunteers from across the country are working on the third edition of the book Oncology Nurse Navigation: Delivering Patient-Centered Care Across the Continuum, and ONS is holding workshops and conducting surveys to obtain real-world data to inform the updated navigation competencies. You can contribute by responding to ONS and ONCC’s April 2024 Oncology Nurse Navigator Competency Modeling Study survey.
Learn more about PIN services in CMS’s 2024 Medicare Physician Fee Schedule final rule and Medicare Learning Network’s resource on health equity services.