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Jennifer Conover

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Hello, I am new to the world of coding, I am almost done with schooling, so forgive me if this question doesn't make sense. A friend of mine who works at a hospital is trying to set up a patient navigation program. It's a relatively new concept, navigators would help cancer patients etc. figure out their way through the medical world. They set up treatments, appointments etc. She asked me how they would bill for this. I do not see any CPT code for this type of thing. Does anyone know how this would be coded?
 
This is not a billable professional-fee service. Nurse navigators are not a new concept; we've had them for years in our Cancer center and our multidisciplinary clinics. Nurse Navigation is an adjunct program designed to facilitate the multi-specialty treatment that severely and chronically ill patients receive. Besides being patient-friendly, nurse navigation helps patient sort through all their different appointments (helping to eliminate no-shows or double bookings), assists with financial aid, community services and caregiver assistance. Nurse navigators are typically employed nurses who are part of a hosptial department such as oncology, Chest Clinic, etc. Their services can be calculated into the facility fee if billing in an outpatient hospital setting, but you can't bill for their services on the 1500.
 
Ok thank you. Just wondering, so the codes 99487-99489 would not work for this? Also what if the navigators are not nurses? My friend is interested in starting a private patient navigator practice. Therefore, it would not be through the hospital or by a nurse. How and can that be coded??
 
You can "code" anything in the book...the trick is to get the payers to reimburse you. Without credentials such as MD, DO, APRN, etc. payers will not credential you. Only certain services can be billed incident-to a physician, and you must meet the rules. 99487-99489 are similar to the TCM codes except they are for chronic care, and they are not (for now) covered by CMS. Since they're not reimbursed, the documentation guidelines are limited to only that which is published in CPT. You can try to bill them out, but most commercial payers are not covering the TCM codes (we're simply going back and billing out the bundled visit as a follow up), so I'm guessing the CCCC (Complex Chronic Care Coordination) codes are also not covered by the commercial payers.

As far as doing this on her own, your friend would need to either have a cash-only practice, or be working under the direct supervision (same suite) as a physician in order to bill incident-to.
 
Even when the TCM and CCC codes are covered these services may be reported by one single provider that oversees all the activities for the month, the patient navigator is only one small piece of these services. To start this service as an independent service would be the same as home health nursing.
 
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