Develop Your Workflow & Payment Pathway
Use this workflow to successfully implement a digital patient navigation program in your system. The guides at the end of this module are designed to support your billing efforts for patient navigation services and to help you recognize when patients may be in financial distress, requiring navigation intervention
Digital Patient Navigation Workflow
The ideal patient navigation workflow consists of three phases and is tailored to the varying experiences of patients and their caregivers.
Patients may engage with navigation services at different points in their journey.
Select the Patient Engagement & Support phase below to start applying the workflow to your patient.
Phase 1
In this phase, you’ll learn how patient intake, including scheduling and records aggregation, prompts initial digital outreach for patient navigation services in support of the initiating oncology visit, including SDOH screening and assessment.
Phase 2
Review how consent obtained at the initiating oncology visit allows patient navigation teams to bill incident-to the physician for digital outreach and assessments under the Principal Illness Navigation (PIN) and Principal Care Management (PCM) pathways.
Phase 3
Gain insight into patient navigation interventions that support patients receiving cancer treatment, including connection to financial assistance resources and ongoing outreach to reassess and manage patient navigation needs and referrals.
Phase 1: Patient Engagement & Support
Step:
Patient Intake
Navigation Staff
Other System Staff
Billing
Clinical intake coordinator outreaches for welcome, introductions, and level setting
Schedule patient appointment with provider
- Patient completion of an intake form in the patient portal, including SDOH screening
- EHR prompt for navigation team outreach to determine eligibility for patient navigation services, including SDOH assessment, as needed
- Initiate aggregation of patient health data if they are coming from outside the health system
*Intake checklist:
An intake form should be completed by all patients and can be filled out directly in the patient portal. When necessary, clinical intake coordinators can facilitate documentation of the form in the EHR. Comprehensive patient intake should include SDOH screening questions and the aggregation of external/existing records in order to identify potential barriers to timely access to care.
SDOH screening: To determine if patients have anticipated barriers to scheduling or attending their next oncology visit, as well as to identify patients who would benefit from more in-depth SDOH assessment, SDOH screening should be prioritized at patient intake. The following topics for coverage are recommended:
- Financial resource strain
- Transportation needs
- Internet connectivity
- Housing/utilities
- Food insecurity
Patients with identified SDOH risk factors at intake should be contacted and notified regarding the expected benefits and potential costs associated with formal, billable SDOH assessment. This can take place prior to or during the initiating oncology visit and is discussed in more detail at the next step in this workflow.
Records aggregation: Clinical intake coordinators should work with the patient and medical records department to collate patient health data that was collected outside of the hospital system, including:
- Past Medical History: Medical conditions, surgeries, treatments, allergies, current medications, and family history
- Pathology: Biopsy results, cytology reports, and histopathology results
- Imaging: X-ray, MRI, CT scan, ultrasound, PET scan, etc.
- Clinical labs: genetic testing, blood tests, and urinalysis
- Legal Documents: DPOA, DNR, etc.
Neglecting to acquire a comprehensive set of patient records can delay the initiating oncology visit and therefore timely cancer care.
Not a Billable Instance
Not a Billable Instance
Digital Outreach & Support for Initiating Oncology Visit
Navigation Staff
Other System Staff
Billing
Patient navigation team conducts virtual outreach via a telehealth appointment or patient portal to ensure access to initiating oncology visit and completion of an SDOH assessment form, as needed
Perform pre-initiating visit outreach and telehealth SDOH assessment to provide support for initiating oncology visit
- SDOH assessment for patients with barriers to accessing their initiating oncology visit
- Connect patient to external resources to support successful oncology visit attendance
- Initiate time-to-treatment monitoring
*The CY 2024 PFS Final Rule established a new stand-alone G code, G0136, to pay for administering an SDOH risk assessment once every 6 months per practitioner per beneficiary.
SDOH risk assessment refers to “a review of the individual’s SDOH needs or identified social risk factors influencing the diagnosis and treatment of medical conditions,” assessing for housing insecurity, food insecurity, transportation needs, utility difficulty, and related factors.
As usual Part B cost sharing and coinsurance apply, beneficiaries or their applicable representatives should be notified and elect to receive the SDOH risk assessment.
The SDOH risk assessment can be performed by auxiliary personnel under the general supervision of the billing practitioner incident to their professional services. It is not required to be furnished on the same day as the associated visit, but is not performed in advance in the absence of one or more known or suspected SDOH needs that may interfere with diagnosis or treatment.
Standardized, evidence-based SDOH risk assessment tools exist and are freely available for your consideration – CMS AHC HRSN Screening Tool, PREPARE Screening Tool.
The SDOH risk assessment service must be associated with a qualifying appointment, which can include evaluation and management (E/M) visits that are also initiating visits for PIN services.
G0136 can be performed via telehealth and has been added to the Medicare Telehealth Services List on a permanent basis.
Billable Code:
- HCPCS code G0136 for SDOH assessment during qualifying visit
- Requires patient consent to services and Part B cost sharing and coinsurance may apply
- Z Codes (Z55–Z65) to document that SDOH needs are being addressed
Billable Code:
- CPT code 96160 for SDOH assessment during qualifying visit
- Requires patient consent as cost sharing and coinsurance may apply
- Z Codes (Z55–Z65) to document that SDOH needs are being addressed
Phase 2: Integration of Clinical & Non-Clinical Navigation
Step:
Initiating Oncology Visit
Navigation Staff
Other System Staff
Billing
Qualifying appointment with oncology clinical care team
*An initiating visit addressing a serious high-risk condition is required to initiate PIN services. Qualifying appointments include evaluation and management (E/M) visits, annual well visits (AWV), psychiatric diagnostic evaluations, or health behavior assessment intervention services (HBAI). Cancer is considered a serious, high-risk condition.
Patient written or verbal consent is required to initiate PIN services, and consent must be documented in patient’s medical record. Patients should be educated that usual Part B cost sharing and coinsurance apply to PIN services.
During the initiating visit, the billing provider establishes the treatment plan and documents how PIN services are reasonable and necessary to help accomplish that plan. This documentation establishes the PIN services as incidental to their professional services so auxiliary personnel may provide PIN services following the initiating visit.
Develop treatment plan, including connection to clinical trials based on diagnostic workup and patient eligibility
- Document patient’s written or verbal consent for Principal Illness Navigation (PIN) services
- EHR prompt for new navigation episode to embed patient navigation in the treatment plan and facilitate incident-to billing
Billable Code:
- CPT codes 99201- 99205
- Qualifies as PIN initiating visit given patient consent to receive PIN services
Billable Code:
- CPT codes 99201- 99205
- Qualifies as PCM initiating visit given patient consent to receive PCM services
Pre-Treatment Outreach & Digital Screening
Navigation Staff
Other System Staff
Billing
Patient navigation team conducts virtual outreach via a telehealth appointment to evaluate readiness for treatment and meets with the patient to digitally assess patient need for navigation services
Digital assessment of financial toxicity risk and Navigation Assessment Score (NAS)
*Assessing patients with cancer for risk of financial toxicity provides the opportunity for navigation teams to make referrals to individualized financial counseling and advocacy services. Validated patient reported outcome measures, such as FACIT-COST, are available for screening and can be digitized for streamlined workflow integration.
Review the CancerX Guide for Digital Distress and Navigation Support Screening to learn more about how to deploy digital COST screening.
*Assessing patient clinical and social risks with the potential to lead to barriers to care enables navigation teams to identify patients with cancer who require a higher level of support for their high-risk medical condition, health-related social needs, and SDOH.
Review the CancerX Guide for Digital Distress and Navigation Support Screening to learn more about how to deploy EHR-embedded tools, such as a Navigation Assessment Score (NAS), to predict patient barriers to access to treatment or completing care.
- If high risk of financial toxicity → refer to financial navigation
- If elevated NAS or increased need for navigation services identified → flag for active treatment outreach in the EHR
- If not seeking treatment → refer out and close the patient navigation encounter
Billable Code:
- HCPCS code G0023 (60 minutes) or HCPCS code G0024 (30 minutes) no more than once per month
- Usual Part B cost sharing and coinsurance may apply
Billable Code:
- CPT codes 99424-99427 no more than once per month
- Cost sharing and coinsurance may apply
Phase 3: Digitally Enabled Patient Navigation Intervention, Management & Monitoring
Step:
Treatment Initiation
Navigation Staff
Other System Staff
Billing
Oncology clinical care team initiates cancer therapy
Make dose modifications and establish pathway for ePRO collection and remote symptom monitoring
- Review patient benefits
- Gather and complete information needed for prior authorization (and as needed, appeals) from EHR and other sources
- Connect patients to prescription drug, co-pay, and other financial assistance programs
*Connecting patients with financial support and resources after assessing them for financial toxicity is an essential step in addressing health-related social needs, ensuring treatment plan adherence, and improving overall clinical and financial outcomes.
Review the Resource Library in the CancerX Guide for Digital Distress and Navigation Support Screening to learn about more processes and resources available for connecting patients with financial resources.
Billable Code:
- HCPCS code G0023 (60 minutes) or HCPCS code G0024 (30 minutes) no more than once per month
- Usual Part B cost sharing and coinsurance may apply
- Z Codes (Z55–Z65) to document that SDOH needs are being addressed
Billable Code:
- CPT codes 99424-99427 no more than once per month
- Cost sharing and coinsurance may apply
- Z Codes (Z55–Z65) to document that SDOH needs are being addressed
Digital Active Treatment Outreach
Navigation Staff
Other System Staff
Billing
Patient navigation team conducts virtual outreach via telehealth appointment to reassess patient needs and to provide ongoing education and advocacy
Make active treatment outreach and place new patient navigation service referrals
Perform ongoing retention outreach, reassess need for patient navigation services using digital screeners, and update referrals, as needed, and as resources will allow
*Reassessing the need for navigation services using the digital NAS screener allows navigation teams to identify barriers to care as they evolve. Higher NAS indicates patients may require a higher level of navigation support and/or interventions including patient education and referral to social support services.
Review the Digitally Assessing Need for Navigation Support section in the CancerX Guide for Digital Distress and Navigation Support Screening to learn more about the NAS and digital solutions supporting scoring.
Billable Code:
- HCPCS code G0023 (60 minutes) or HCPCS code G0024 (30 minutes) no more than once per month
- Usual Part B cost sharing and coinsurance may apply
- Z Codes (Z55–Z65) to document that SDOH needs are being addressed
Patient navigation services are crucial for patients and their families managing the challenges associated with a cancer diagnosis and treatment.
New and existing payment pathways enable reimbursement for non-clinical navigation services provided to patients with cancer by credentialed patient navigators as well as clinical staff. Digital health solutions help address resource constraints and enable scaled patient triage and tracking with automated data collection for billing purposes.
Review the CancerX Reimbursement Guide for Non-Clinical Patient Navigation for support maneuvering the complex payment pathways available to publicly- and commercially-insured patients.
Billable Code:
- CPT codes 99424-99427 no more than once per month
- Cost sharing and coinsurance may apply
- Z Codes (Z55–Z65) to document that SDOH needs are being addressed
Patient navigation services are crucial for patients and their families managing the challenges associated with a cancer diagnosis and treatment.
New and existing payment pathways enable reimbursement for non-clinical navigation services provided to patients with cancer by credentialed patient navigators as well as clinical staff. Digital health solutions help address resource constraints and enable scaled patient triage and tracking with automated data collection for billing purposes.
Review the CancerX Reimbursement Guide for Non-Clinical Patient Navigation for support maneuvering the complex payment pathways available to publicly- and commercially-insured patients.
The CancerX team thanks the team at UNC Lineberger Comprehensive Cancer Center for their invaluable support of this Blueprint resource
At-a-Glance Guide: Financial Distress & Navigation Support
Use this guide to leverage digital health solutions to support the administration of distress screening tools for financial toxicity and navigation support. It includes use cases for digital assessment and a resource library for action after assessment.
DownloadAt-a-Glance Guide: Patient Navigation Billing & Reimbursement
Billing pathways for patient navigation can be complex. Use this guide to navigate the complex payment pathways for patient navigation to generate revenue and sustain the critical non-clinical support services they provide.
DownloadUse the Blueprint
The Digitally Enabled Patient Navigation Blueprint features several resources that you can use to adapt existing technology and leverage reimbursement pathways to support patient navigation – from pre-treatment to active treatment to survivorship.
Click through the three sections of the Blueprint below for related resources.
Covers approaches patient navigators and health information technologists can take to adapt existing EHR platforms and develop EHR-enabled workflows to fit their patient navigation needs.
Features a digitally enabled workflow, recommended approaches for digital distress screening, and billing information for patient and financial navigators who need information on digital patient triage, navigation interventions, and reimbursement pathways.
