Reimbursement for Nurse Navigation: It Can Be Done

Oncology Nursing News, December 2010, Volume 4, Issue 6

Cancer centers and institutions are embracing the role of nurse navigation as part of the changing environment of oncology care.

Cancer centers and institutions are embracing the role of nurse navigation as part of the changing environment of oncology care. Unfortunately, formal reimbursement for nurse navigation services is lacking.

At the Second Annual NCONN Conference, Matthew Farber, MA, director of provider economics and public policy for the Association of Community Cancer Centers, discussed methods for reimbursement.

Currently, navigation is done essentially without reimbursement and how it is funded varies. Hospitals and cancer institutions are funding navigation from general operating budgets, charitable donations, and government and industry grants. Furthermore, hospitals and cancer centers participating in the National Cancer Institute Community Cancer Centers Program are using grant money for navigator programs. These institutions will be responsible for funding programs after the grant money expires.

Formal Reimbursement

A valid current procedural terminology (CPT) code is needed for formal reimbursement for nurse navigation. “Right now there is no set reimbursement code that you’re writing down or no set modifier that you add to a CPT code that identifies the work you’re doing,” explained Farber.

CPT codes are assigned a relative value unit (RVU) to determine the amount of work associated with the code. RVUs are assigned by the America Medical Association’s RVS (Relative Value Scale) Update Committee (RUC). To get a new CPT code, an application needs to be submitted to the CPT Editorial Panel & Advisory Committee. Because codes are updated January 1 of each year, it takes a year to find out if a new code is granted. Certain criteria must be met for the committee to consider a new code. If the editorial panel approves the request, it then moves onto RUC for valuation.

“For the application, the key is to demonstrate that the service is distinct and differs from other services already being offered,” Farber advised. “It’s important to be very clear on how this is a unique service.”

Working with advocacy organizations is also prudent, as well as attending the CPT Editorial Panel & Advisory Committee meeting. “Attend the meeting when they’re talking about your application. This can be vital if they have questions [because] you can be the expert they turn to,” said Farber.

Appeal to Congress

Cancer organizations have been instrumental in getting bills introduced to improve the delivery of cancer care. Farber cited 2 examples: the Assuring and Improving Cancer Treatment Education and Cancer Symptom Management Act of 2009 (HR 1927) and the Comprehensive Cancer Care Improvement Act of 2009 (HR 1844). Congressional action on these bills is unlikely this year, noted Farber.

“Nothing is really going to happen this year because everyone in Congress is tired of talking about healthcare. We just passed this massive healthcare reform bill so Congress wants to talk about something else or doesn’t want to spend any more money.”

Although the newly passed Patient Protection and Affordable Care Act (section 3510) would extend patient navigator programs for 5 years at $4 million a year, Farber said it will not be continued next year because the money was not appropriated for it.

If institutions want navigation legislation passed, they should find a champion in Congress to introduce the bill. Farber said much of the initial legwork falls on the group wanting the legislation and their ability to rally members to get involved.

Seek Private Payers for Reimbursement

Efforts are under way to have private payers reimburse for navigation services. “You really have to promote how nurse navigation services and patient navigation services can promote quality of care for patients,” said Farber. “Also payers not only want to do this, but many want to show they’re promoting quality of care while keeping costs down.”

One way of keeping costs down is bundled payments for episodic care. In order for nurse navigation services to be included in bundled payments, “You need to be vocal and communicate with these private payers and third-party payers that this is an integral part of oncology care and without this the patient wouldn’t have this good quality of care,” said Farber.

In addition to provider advocacy organizations, patient advocacy organizations can benefit reimbursement efforts by mobilizing patients to talk about the importance of these resources—especially when speaking with Congress and government agencies. “Not only do your patients love you, but they will speak on your behalf and advocate for you,” Farber said.

“There are opportunities to get reimbursed. It’s a long process and there are no guarantees. Don’t get discouraged if it doesn’t work out the way you want it,” said Farber. “I know there are a lot of people who support navigation. This is an integral part of cancer care and it’s only going to grow in the future.