Oncology Insights: October 2024 - Prime Therapeutics
Oncology Case Management and Navigation: How do they differ?
However, the distinction between case management and navigation services may be unclear. Case management is implemented by a health care professional, typically a nurse and has varying titles such as Discharge Planners, Life Coaches, Navigators, Population Health Managers, Social Workers, or Care Managers.1 According to the Case Management Society of America, “case management is a collaborative process of assessment, planning facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes”.1 A case manager may also assist with clinical trial enrollment and help to decrease hospital readmission with the goal of improving health outcomes, enhancing the health care experience, and reducing cost of care.2,3
Currently, billing for cancer case management activities uses the CMS procedural terminology codes for care management for chronic conditions.⁷
The American Cancer Society defines patient navigators as those who help patients, families, and caregivers decrease barriers to accessing quality health care including financial and psychosocial resources. In general, a navigation team consists of clinical and non-clinical members and are typically employed by a health care-, advocacy-, and/or community-based organization.⁸ Oncology patient navigation begins with prevention and detection and continues through diagnosis, treatment, survival, and end-of-life.
The Enhanced Oncology Model (EOM) includes patient navigation as part of the infrastructure to support patients and improve care. In the EOM, navigation services include connecting patients to follow-up and support services, providing access to clinical trials, helping patients navigate the health care system to help “drive transformation and improve care coordination in oncology care by preserving and enhancing the quality of care.”⁹
Savings associated with navigation have also proven difficult to quantify. However, a study by Worland and colleagues found a total mean cost of care decrease of $459 PMPM for navigated group compared to non-navigated group.
In the 2024 CMS completed coding and reimbursement for Principal Illness Navigation (PIN) services, which allows oncology practitioners can bill and receive Medicare payment for patient navigation services performed under the direction of a billing practitioner.10,11
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References:
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Case Management Society of America. What is Case Management. Retrieved on Oct 12, 2024, from https://cmsa.org/case-management-at-a-glance/.
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Hunter T, Nelson JR, Birmingham J. Preventing readmissions through comprehensive discharge planning. Prof Case Manag. 2013 Mar-Apr;18(2):56-63; quiz 64-5. doi: 10.1097/NCM.0b013e31827de1ce.
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Fors, M. The Role of Case Management: Improving Outcomes and Addressing Health Disparities in Cancer Care. Oncology Nursing. News Educating Nurses and Providers. (2021). Retrieved on Oct 14, 2024, from https://www.oncnursingnews.com/view/the-role-of-case-management-improving-outcomes-and-addressing-health-disparities-in-cancer-care.
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Wang N, Chen J, Chen W, et al. The effectiveness of case management for cancer patients: an umbrella review. BMC Health Serv Res. 2022 Oct 14;22(1):1247. doi: 10.1186/s12913-022-08610-1.
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Klaehn A, Jaschke J. Cost-effectiveness of Case Management: A Systematic Review. Retrieved on Oct 11, 2024 from https://www.ajmc.com/view/cost-effectiveness-of-case-management-a-systematic-review.
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Hudon C, Chouinard MC, Pluye P, et al. Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review. Ann Fam Med. 2019 Sep;17(5):448-458. doi: 10.1370/afm.2419.
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Codify by AAPC. Retrieved on Oct 14, 2024 from https://www.aapc.com/codes/cpt-codes-range/99366-99368/#:~:text=99499%2D99499-,Case%20Management%20Services,Medical%20Team%20Conferences
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American Cancer Society. National Navigation Roundtable. Retrieved on Oct 14, 2024 from https://navigationroundtable.org/patient-navigation/about-patient-navigation/#:~:text=Patient%20navigation%20is%20the%20individualized,quality%20health%20and%20psychosocial%20care.
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Centers for Medicare and Medicaid Services. Retrieved on Oct 14, 2024 from https://www.cms.gov/priorities/innovation/innovation-models/enhancing-oncology-model
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Worland SC, Albin M, Dorsey B, et al. Evaluating the effect of a scalable cancer-navigation program on total cost of care. Retrieved on October 13, 2024 from https://ascopubs.org/doi/10.1200/JCO.2022.40.28_suppl.004.
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ASCO in Action: News, Advocacy, and Analysis on Cancer Policy. Retrieved on Oct 14, 2024 from https://society.asco.org/news-initiatives/policy-news-analysis/resources-available-using-new-patient-navigation-codes.