Frequently Asked Questions
Navigation Billing FAQ
Answers to the most common questions about navigation billing, documentation, and compliance
.svg)
.svg)
General Billing Enablement
What codes can be used for oncology navigation billing?
Depending on the patient and payer, navigation services may be billed using:
- PIN codes (Principal Illness Navigation): G0023, G0024, G0140, G0146, G0019, G0022.
- PCM codes (Principal Care Management): 99424, 99425, 99426, 99427
- CHI (Community Health Improvement): G0019, G0022
Do I need special certification to bill navigation codes?
- No certification needed for clinical staff: MD, NP, PA
- Navigator certification is needed for auxiliary staff
- Certification example: https://www.cancer.org/health-care-professionals/resources-for-professionals/patient-navigator-training.html)
Is patient consent required?
Yes. Verbal or written consent is required to bill for navigation. Time spent navigating the patient prior to obtaining the consent is not billable.
Will the patient have a copay for navigation services?
Possibly.
Navigation, PIN, and care management services are billed to insurance, and standard cost-sharing rules may apply depending on the patient’s plan. In some cases, patients may be responsible for:
- Copay
- Coinsurance
- Deductible
Which payors support navigation billing, and is prior auth required?
In general, navigation-related codes such as PIN and PCM are most commonly supported by:
- Medicare
- Medicare Advantage plans
- Some commercial insurers
- Some Medicaid plans (state dependent)
HMO and commercial plans usually require prior authorization, but coverage policies may vary by region and contract.
Does navigation have to be face-to-face?
No. Most navigation codes allow non-face-to-face time.
Time Tracking & Encounter Rules
Is billing based on each encounter?
No. Billing is usually based on:
- Total monthly time
- Threshold minutes
- Code tiers
Example:
- First 30 min
- Additional 30 min
Do I need a minimum amount of time?
Yes. Each code has thresholds.
Examples:
- 30 minutes per month
- 60 minutes per month
- Additional increments
Billing without reaching thresholds is not allowed.
Can I bill the same patient every month?
Yes, if:
- Time threshold met
- Patient eligible
- Services documented
Are call preparation and documentation times billable?
Yes, if it is related to patient care.
Examples that may count:
- Reviewing the chart before the call
- Reviewing referral
- Reviewing imaging/pathology reports
- Preparing care coordination notes
- Preparing documentation for patient outreach
- Writing encounter notes
- Completing navigation documentation
- Updating care plan
Preparation and documentation must be directly related to the patient.
Can I bill for texting, secure messaging, and emails?
No. Texting and emailing is excluded from billable activities due to the fact that tech savviness of staff affects communication speed.
Can I bill for calls to other providers?
Yes, if related to patient care.
Examples:
- Calling surgeon's office
- Calling radiation oncology
- Calling the imaging center
- Calling pathology
- Calling pharmacy
Can I bill for calls to insurance companies?
Often yes. Calls to insurance may count if they are:
- On behalf of the patient
- Required for treatment
- Related to authorization
- Related to coverage issues
- Related to appeals
These are typically considered care coordination.
Is call time spent on hold or while navigating an IVR system billable?
This is a gray zone. If the staff is actively working on the case, e.g., in the patient's chart, it may count.
Best practice
- Spend time in the patient chart while on call
- Include this narrative in the encounter documentation
- Exclude calls that consist 100% of wait time or navigating via an IVR system
Can EMR notes alone support billing?
Usually not enough. Most EMRs do not track:
- Time
- Monthly totals
- Navigation categories
- Code eligibility
Additional tracking is usually needed.
XpediteMD Platfrom
How does XpediteMD help with navigation billing?
XpediteMD helps by:
- Tracking navigation encounters
- Tracking time automatically
- Mapping encounters to CPT / HCPCS codes
- Generating billing summaries
- Identifying eligible patients
- Providing audit-ready documentation
This allows practices to capture revenue from work they already do.
Can XpediteMD help identify missed billing opportunities?
Yes. The platform can show:
- Patients with enough time but not billed
- Patients with no or declined consent
- Incomplete encounters
- Monthly revenue opportunities
This helps maximize compliance and revenue.
Can XpediteMD help identify patients in need of navigation?
Yes. The platform can help track:
- Patient with delayed navigation milestones
- Patients at risk meeting the Time-to-Treatment target
Does the XpediteMD Platform produce billing documentation?
Yes. For each consented patient who met at least one threshold for at least one navigation CPT code, the platform will produce a billing PDF.
Does the XpediteMD Platform bill for the qualified patients?
No. You still need to use your biller to submit claims.
Request a Demo Today
And see the XpediteMD Cancer Patient Navigation
Platform in Action
.svg)
.svg)
