2024 CMS Reimbursement for Principal Illness Navigation (PIN) and the Certified Oncology Social Worker (OSW-C^TM)

Patient navigation has been shown to improve cancer outcomes, improve patient satisfaction and reduce health disparities. In January 2024, the Centers for Medicare & Medicaid Services (CMS) established coding and payment for Principal Illness Navigation (PIN) services. These services aim to improve health equity in patients dealing with serious, high-risk conditions.

PIN was defined as being for serious, high-risk conditions with a duration of three (3) months or more and increased risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death. In addition, the condition may also require monitoring/updating of a care plan, adjustments to treatment/medications or support from a caregiver. Cancer is among the examples of a serious, high-risk condition.

The CMS rule for PIN outlines requirements for those providing navigation. CMS specifies that individuals must meet applicable State requirements, including certification or licensure. In States with no applicable requirements, those providing PIN services must be trained or certified in the following specific competencies:

• Patient and family communication;
• Interpersonal and relationship-building;
• Patient and family capacity building;
• Service coordination and systems navigation;
• Patient advocacy, facilitation, individual and community assessment;
• Professionalism and ethical conduct; and,
• Development of an appropriate knowledge base, including specific certification or training on the serious, high-risk condition, illness, or disease being addressed

While not expressly stated in the CMS rule, the language largely skews towards non-clinical navigators, which has left some questions for social workers providing navigation services regarding the rule. The competencies delineated in the CMS rule are components of the OSW-C^TM Competencies and validated through obtaining the Certified Oncology Social Worker (OSW-C^TM) certification from the Board of Oncology Social Work Certification (BOSWC^TM).

How training should be documented is not clear in the rule. BOSWC recommends that oncology social workers ensure their licensure and any education that is navigation specific is documented with their organizations.

It is important that oncology social workers are familiar with the Oncology Navigation Standards of Professional Practice, which outline the differences and similarities in the practice between non-clinical and clinical (social worker and nurse) roles to optimize collaboration.

Further information on the CMS PIN services can be found in CMS’ CY 2024 Medicare PFS final rule and the Medicare Learning Network resource on Health Equity Services.