Issue link: https://beckershealthcare.uberflip.com/i/1546376
16 PATIENT & CAREGIVER EXPERIENCE CMS expands navigation coverage: What to know By Elizabeth Gregerson F or CMS' 2026 final rule, the agency broadened who can bill Medicare for patient navigation services. While the agency's reimbursement pathway is still less than three years old, U.S. health systems have used patient navigators to help people move through complex, high-stakes diagnoses for decades. CMS made two updates in the 2026 final rule, changing the Community Health Integration service description from "social determinants of health" to "upstream drivers," and clarifying that clinical social workers, marriage and family therapists, and mental health counselors can bill directly for CHI and Principal Illness Navigation services tied to a mental illness diagnosis or treatment. ose updates followed a 2025 request for information CMS issued seeking feedback on the codes. e 2027 proposed rule, released July 14, does not propose further changes to reimbursement for navigation services. How do health systems use patient navigators? Navigation services help patients move through the healthcare system to get the care they need. Navigators can: • Coordinate appointments and care transitions across providers, home care and community-based organizations. • Provide health education so patients and families understand a diagnosis and treatment options. • Help patients communicate with their care team. • Connect patients to financial assistance, transportation and other social services. • Offer emotional support and, in some cases, peer support from someone with lived experience of the condition. Adding a dedicated oncology nurse navigator to new patient triage processes improved scheduling accuracy and timeliness while improving workplace satisfaction among new patient coordinators, according to research presented by Dana-Farber nurses at the 2026 Oncology Nursing Society Congress in San Antonio. How does Medicare cover patient navigation services? CMS created dedicated billing codes for navigation services in the 2024 Physician Fee Schedule final rule, effective Jan. 1, 2024 — the first time Medicare paid directly for this work. • Principal Illness Navigation: Billed under G0023 and G0024, these codes cover navigation services for patients with a serious, high-risk condition that is expected to last at least three months. e condition must put them at significant risk of hospitalization, nursing home placement, functional decline or death. Cancer, chronic obstructive pulmonary disease, congestive heart failure, dementia, HIV/AIDS, severe mental illness and substance use disorder are named as qualifying conditions. • PIN-Peer Support: Billed under G0140 and G0146, these codes cover care management services for patients with serious, high- risk behavioral health conditions. Nonclinical support services are delivered by certified peer specialists with lived-experience navigating a mental health condition. • Community Health Integration: Billed under G0019 and G0022, these codes cover services provided by community health workers that address unmet social or environmental needs that affect a patient's ability to access care. A billing practitioner — physician, nurse practitioner, physician assistant, certified nurse midwife or clinical psychologist for behavioral health conditions — must complete an initiating visit before navigation services begin. e navigator then delivers services under that practitioner's supervision, with services billed by time and place of service. How much are navigators used across hospitals and health systems? According to the most recent data published by CMS, adoption of Medicare's navigation billing codes nationally in 2024 was limited. Image Credit: Adobe Stock