Using HCPCS Codes G0023, G0024, G0140 and G0146 for Principal Illness Navigation (PIN) Services

Starting in 2024, the Centers for Medicare & Medicaid Services (CMS) finalized new Healthcare Common Procedure Coding System (HCPCS) codes to pay for providing PIN services.

What are PIN services?

There are two types of PIN services:

General PIN services address conditions such as cancer, chronic obstructive pulmonary disease, and congestive heart failure.
Principal Illness Navigation-Peer Support (PIN-PS) services are intended for patients with a high-risk behavioral health condition.

PIN services are meant to provide additional support to patients with:

A serious, high-risk condition (for PIN-PS, a serious, high-risk behavioral health condition) that is expected to last at least three months and places the patient at significant risk of:
- Hospitalization
- Nursing home placement
- Acute exacerbation or decompensation
- Functional decline or death.

A condition that requires development, monitoring, or revision of a disease-specific care plan and that may require frequent adjustment in the medication or treatment regimen or substantial assistance from a caregiver.

PIN services include items such as:

Health system navigation assistance
Person-centered planning
Identifying or referring patient and caregiver or family, if applicable, to supportive services
Patient self-advocacy promotion
Facilitating access to community-based resources

Read the CMS PIN code descriptors

Principal illness navigation 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, 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 and including unmet SDOH needs (that aren’t separately billed)
- 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 communication
- Coordinating receipt of needed services from health care practitioners, providers, and facilities; home- and community-based service providers; and caregiver (if applicable)
- Communicating 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 health care, 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

Leveraging knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals

Principal illness navigation services, additional 30 minutes per calendar month (List separately in addition to G0023)

Principal illness navigation - 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, in the following activities:

Person-centered interview, performed to better understand the individual context of the serious, high-risk condition
- Conducting a person-centered interview to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors, and including unmet SDOH needs (that aren’t billed separately)
- Facilitating patient-driven goal setting and establishing an action plan
- Providing tailored support as needed to accomplish the person-centered goals in 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 communication
- Assisting the patient in communicating with their 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, goals, preferences, and desired outcomes, including cultural and linguistic factors
- 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

Developing and proposing strategies to help meet person-centered treatment goals and supporting the patient in using chosen strategies to reach person-centered 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 person-centered diagnosis and treatment goals

Leveraging knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals

Principal illness navigation - peer support, additional 30 minutes per calendar month (List separately in addition to G0140)

What are the requirements for PIN services?

Patients must have an initiating visit before receiving PIN services. PIN initiating visits include:

Evaluation and management visits, including the E/M provided as part of transitional care management
Excludes low-level visits (e.g., 99211) performed by clinical staff
Inpatient and observation visits, emergency department visits, and skilled nursing facility visits would not be considered an initiating visit
Annual wellness visits (when performed by a practitioner who will bill for PIN services)
Psychiatric diagnostic evaluation (CPT code 90791)
Health Behavior Assessment and Intervention (CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168)

Subsequent PIN services may be provided by auxiliary staff, such as patient navigators and peer support specialists. Auxiliary staff may be employed by the practice or contracted through an external organization. PIN services do not need to be provided in-person, but CMS expects many aspects of PIN services will involve direct patient contact.

Are there specific training requirements for those providing PIN services?

PIN services are provided incident-to the professional services of a physician or other billing practitioner under general supervision.

Auxiliary staff must meet all incident-to requirements and any state requirements, including licensure. In states with no applicable requirements, auxiliary staff 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 specific certification or training on the serious, high-risk condition, illness or disease being addressed.

When there are not applicable state requirements, auxiliary staff providing PIN-PS services should receive training that is consistent with the National Model Standards for Peer Support Certification published by the Substance Abuse and Mental Health Services Administration.

Auxiliary personnel may be employees, leased employees, or independent contractors of the billing practitioner.

Is beneficiary consent required for PIN services?

Yes. Consent may be verbal or written but must be documented in the medical record. Consent should include explaining to the patient that cost-sharing will apply. Consent should be obtained annually.

Are PIN services subject to deductible and coinsurance?

Yes. PIN services are subject to deductible and coinsurance. Some supplemental insurance plans may cover the patient’s cost-sharing.

What are the documentation requirements for PIN services?

In addition to documenting patient consent, documentation must include the amount of time spent with the patient and the nature of the activities, including how they relate to the treatment plan. Any unmet social needs addressed by PIN services must also be documented. CMS encourages practices to document “Z codes,” when applicable.

How are PIN services billed?

PIN services are billed monthly and are reported by the physician or practitioner who provided the initiating visit. PIN services may only be reported by the billing physician or practitioner once per month for any single serious high-risk condition.

Do private payers cover PIN services?

Most Medicare Advantage plans cover PIN services. For commercial plans, coverage varies by payer. Check with your provider relations representatives for additional information regarding their policies. Verify the patient’s benefits before providing PIN services.

How are PIN services different from other care management services (e.g., chronic care management [CCM])?

PIN services are like services such as CCM in that they provide additional, tailored support to patients. CCM services are primarily focused on clinical aspects of care and limited to patients with two or more chronic conditions. PIN services are focused on patient support and social aspects of care.

Can PIN services and other care management services (e.g., CCM) be billed concurrently?

Yes. As long as the requirements for both services are met, PIN and other care management services may be reported in the same month. Time and effort for both services must be unique – do not count the same time and work more than once. PIN and PIN-PS services should not be reported concurrently for the same condition.

How are community health integration (CHI) and PIN services different?

CHI and PIN services are very similar. A key difference in the services is that CHI services are focused on addressing patients’ unmet social needs. PIN services are focused on helping patients with a serious high-risk condition navigate the health care system and guiding them through their course of care. Patients receiving PIN services may also have unmet social needs, but it is not a requirement.