On Nov. 9, 2023, the American Medical Association released a Current Procedural Terminology (CPT®) Assistant Special Edition (PDF) on the appropriate CPT codes for reporting oncology navigation services. This work is the culmination of over six months of collaboration with the Biden administration and offers authoritative CPT guidance directly from the AMA on appropriate reporting for these vital services.
Oncology navigation services sit at the heart of the White House Cancer Moonshot’s stated goal to mobilize a national effort to end cancer as we know it.
Key to the Cancer Moonshot’s navigation efforts is the Oncology Navigation Standards of Professional Practice, which describe the knowledge and practices that cancer navigators should provide to deliver high-quality, competent, and ethical services to people affected by cancer. These services have been designed and may be provided by a variety of health care personnel. The Special Guidance article provides guidance on the appropriate use of CPT codes in reporting these services.
Per the Oncology Navigation Standards of Professional Practice, two categories of cancer-navigation services are provided to patients:
- Clinical Navigation Services focus on clinical care, clinical coordination, and clinical education. These services are typically provided by licensed clinical staff, such as registered nurses or licensed clinical social workers. However, in some care settings, clinical navigation services may be provided by physicians or qualified healthcare professionals (QHP) such as physicians assistants or nurse practitioners.
- Patient Navigation Services focus on improving access to care related to social determinants of health. Patient navigation services may be provided by a variety of individuals, including community health workers. A patient navigator may not have clinical training.
In some care settings, nurse navigators may provide both types of navigation services.
Principal Care Management codes 99424-99427, which were established in 2022, represent services that “focus on the medical and/or psychological needs manifested by a single, complex chronic condition expected to last at least three months and includes establishing, implementing, revising, or monitoring a care plan specific to that single disease,” and are not limited to use with oncology patients.
These services help improve coordination of care, reduce avoidable hospital services, decrease overutilization of services, improve patient engagement, and decrease care fragmentation due to decentralized patient throughput.
Codes 99424 and 99425 may be reported when a physician or other QHP personally provides the service; while codes 99426 and 99427 may be reported when services are provided by clinical staff under the direction of a physician or other QHP.
In response to the growing importance of navigator services, in the 2024 Medicare Payment Final rule, CMS created HCPCS codes to describe Principal Illness Navigation (PIN) services. According to CMS, these services involve a person-centered assessment to better understand the patient’s life story, care coordination, contextualizing health education, building patient self-advocacy skills, health system navigation, facilitating behavioral change, providing social and emotional support, and facilitating access to community-based social services to address unmet social determinations of health (SDOH) needs. CMS also finalized an additional set of PIN codes to describe services involving auxiliary personnel, such as peer support specialists to better support individuals with behavioral health conditions like severe mental illness and substance use disorder.
The Cancer Moonshot, which was initially launched and funded through the 21st Century Cures Act passed in 2016, is a national effort to end cancer. In February 2022, President Biden and the First Lady reignited the Cancer Moonshot with two main goals:
- Cut today’s age-adjusted death rate from cancer by at least 50% in the next 25 years, preventing more than 4 million cancer deaths by 2047.
- Support and center patients and their caregivers living with and surviving cancer.
Increasing the use of effective cancer-navigation services is an important tool not only to boost support for patients but also to reduce cancer disparities and improve health outcomes.