Principal Illness Navigation Services
What are Principal Illness Navigation (PIN) Services?
The Centers for Medicare & Medicaid Services (CMS) began reimbursing for Principal Illness Navigation (PIN) services on January 1, 2024. PIN services are navigation services provided by auxiliary personnel or peer support specialists for Traditional Medicare patients with a serious, high-risk condition or illness.
PIN services help patients navigate treatment for their health condition, including any unmet social needs. PIN services include:
- Person-centered planning
- Care coordination and health system navigation
- Referral to supportive services and community-based resources
- Patient self-advocacy skill promotion
Serious, high-risk conditions or illnesses eligible for PIN services include cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dementia, HIV/AIDS, severe mental illness, or substance use disorder. To be eligible for PIN services, the patient should have one of the following:
- One serious, high-risk condition or illness expected to last at least three months that places the patient at risk of hospitalization, nursing home placement, acute exacerbation or decompensation, functional decline, or death.
- A condition requiring 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
- For PIN-Peer Support services, have one serious, high-risk behavioral health condition expected to last at least three months that places the patient at risk of hospitalization, nursing home placement, acute exacerbation or decompensation, functional decline, or death.
Why provide PIN Services?
PIN services are intended to support patients in managing their serious medical condition and navigating healthcare and social services that can support treatment and management. PIN services can help enhance your practice's efficiency and improve patient compliance and satisfaction. These services can further support practitioners achieve quality goals related to potentially avoidable utilization and health outcomes.
Who can provide PIN Services?
PIN services require an initiating visit with a billing practitioner prior to the start of PIN services. During an initiating visit, the billing practitioner should identify the need for PIN services, create a treatment plan describing how PIN services are needed, and establish the PIN services. The billing practitioner can be a physician, nurse practitioner, physician assistant, certified nurse midwife, or clinical psychologist (for behavioral health conditions).
Auxiliary personnel, including community health workers (CHWs), nurses, social workers, peer navigators, or peer support specialists may perform PIN services incidental to the billing practitioner under general supervision. The same practitioner bills for the subsequent CHI services provided by the auxiliary personnel.
Auxiliary personnel who provide PIN services may be employed by the billing practitioner or may be external to, and under contract with, the practitioner. For example, a physician practice may contract with a community-based organization employing CHWs or other auxiliary personnel if they meet all “incident to” requirements and conditions for payment of PIN services.
If your practice chooses to use auxiliary personnel, note that they must meet all applicable state requirements, including licensure. If your state does not have any applicable requirements, these personnel must be certified and trained in the following competencies:
- Patient and family communication
- Interpersonal and relationship-building skills
- Patient and family capacity building
- Service coordination and systems navigation
- Patient advocacy, facilitation, individual and community assessment
- Professionalism and ethical conduct
- Development of an appropriate knowledge base, including of local community-based resources
For PIN-Peer Support services, if there are no applicable state requirements, training must be consistent with the National Model Standards for Peer Support Certification published by Substance Abuse Mental Health Services Administration (SAMHSA).
What is required for a PIN initiating visit?
PIN services require an initiating visit with a billing practitioner prior to the start of PIN services. An initiating visit can be:
- An Evaluation and Management (E/M) visit, with the exception of level 1 visits performed by clinical staff,
- An Annual Wellness Visit (AWV), or
- A psychiatric diagnostic evaluation or Health Behavior Assessment and Intervention
During the initiating visit, the practitioner should determine medical necessity for PIN services and create a treatment plan. The practitioner or the auxiliary personnel providing CHI services must get patient consent in advance of providing PIN services to ensure patients are aware of cost sharing requirements. Consent can be written or verbal and documented in the patient's medical record.
What are the billing codes for PIN Services?
There are four HCPCS codes for PIN services.
Two HCPCS codes can be used for PIN services provided by certified or trained auxiliary personnel under the direction of a physician or other practitioner:
- G0023: PIN services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator; 60 minutes per calendar month.
- G0024: PIN services, additional 30 minutes per calendar month (List separately in addition to G0023).
Two HCPCS codes can be used for PIN-Peer Support services:
- G0140: PIN-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.
- G0146: PIN-Peer Support, additional 30 minutes per calendar month (List separately in addition to G0140).
PIN services can be provided once per month per practitioner. PIN and PIN-Peer Support services cannot be billed concurrently for the same condition or illness. Other care management services can be furnished in the same month if the services are medically reasonable and necessary, meet the requirements, and efforts are not counted more than once.
How do I document PIN Services in my electronic health record (EHR)?
During the initiating visit, the billing practitioner should document the patient's treatment plan and the medical necessity for PIN services. Further, the billing practitioner must document patient consent before providing PIN services and then annually. The practitioner should also ensure the patient is aware of cost sharing and that services may only be provided by one practitioner per month.
When providing PIN services, the amount of time spent with the patient and the types of activities conducted should be documented in the patient's medical record. ICD-10 Z-codes can be used to in documentation.
Are there any special considerations for Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs)?
RHCs and FQHCs can bill for PIN services using the HCPCS Code G0511, either alone or with other payable services. CMS allows RHCs and FQHCs to bill concurrently for care management services. This means that RHCs and FQHCs can provide PIN, Transitional Care Management (TCM), and other care management services for the same patient in the same service period.
As of January 1, 2024, RHCs and FQHCs can bill G0511 multiple times in a calendar month so long as they are: “medically reasonable and necessary, meet all requirements, and not be duplicative of services paid to RHCs and FQHCs under the general care management code for an episode of care in a given calendar month.” This change reflects previous guidance that stated FQHCs and RHCs could only bill G0511 once per month.
Additionally, note that group health behavioral assessment and intervention (HBAI) services (CPT codes 96164, 96165, 96167, and 96168) are not qualifying visits for RHCs or FQHCs and may not serve as initiating visits for PIN services.
Resources
- Care Management, Centers for Medicare & Medicaid Services
- Health Equity Services in the 2024 Physician Fee Schedule Final Rule, Centers for Medicare & Medicaid Services
- Health-Related Social Needs FAQ, Centers for Medicare & Medicaid Services
- CMS Billing Lingo, Defined!, National Association of Community Health Centers
- Payment Reimbursement Tips: Principal Illness Navigation (PIN), National Association of Community Health Centers
- Summary of Medicare Care Management Services Billed Using G0511, National Association of Community Health Centers
- Care Management Services and Patient Navigation Services: A Comparison, American Society of Clinical Oncology
- Understanding the Medicare Physician Fee Schedule Billing Codes for: Community Health Integration (CHI), Principal Illness Navigation (PIN), Principal Illness Navigation – Peer Support (PIN-PS) Services, Partnership to Align Social Care
- Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes, Centers for Medicare & Medicaid Services Office of Minority Health
- Healthcare Guide to Contracting with CBOs, Partnership to Align Social Care
Last Updated: 11/26/2024
Last Reviewed: 11/26/2024