G0023

Principal illness navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator; 60 minutes per calendar month, in the following activities: person-centered assessment, performed to better understand the individual context of the serious, high-risk condition. ++ conducting a person-centered assessment to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors and including unmet sdoh needs (that are not separately billed). ++ facilitating patient-driven goal setting and establishing an action plan. ++ providing tailored support as needed to accomplish the practitioner's treatment plan. applicable) to appropriate supportive services. community-based care coordination. ++ coordinating receipt of needed services from healthcare practitioners, providers, and facilities; home- and community-based service providers; and caregiver (if applicable). ++ communication with practitioners, home-, and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors. ++ coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians; follow-up after an emergency department visit; or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities. ++ facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address sdoh need(s). provided by the patient's treatment team with the patient's individual needs, goals, preferences, and sdoh need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making. patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services (as needed), in ways that are more likely to promote personalized and effective treatment of their condition. patient access healthcare, including identifying appropriate practitioners or providers for clinical care, providing the patient with information/resources to consider participation in clinical trials or clinical research as applicable. change as necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach person-centered diagnosis or treatment goals. support to help the patient cope with the condition, sdoh need(s), and adjust daily routines to better meet diagnosis and treatment goals. knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals

The HCPCS code for principal illness navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator; 60 minutes per calendar month, in the following activities: person-centered assessment, performed to better understand the individual context of the serious, high-risk condition. ++ conducting a person-centered assessment to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors and including unmet sdoh needs (that are not separately billed). ++ facilitating patient-driven goal setting and establishing an action plan. ++ providing tailored support as needed to accomplish the practitioner's treatment plan. applicable) to appropriate supportive services. community-based care coordination. ++ coordinating receipt of needed services from healthcare practitioners, providers, and facilities; home- and community-based service providers; and caregiver (if applicable). ++ communication with practitioners, home-, and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors. ++ coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians; follow-up after an emergency department visit; or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities. ++ facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address sdoh need(s). provided by the patient's treatment team with the patient's individual needs, goals, preferences, and sdoh need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making. patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services (as needed), in ways that are more likely to promote personalized and effective treatment of their condition. patient access healthcare, including identifying appropriate practitioners or providers for clinical care, providing the patient with information/resources to consider participation in clinical trials or clinical research as applicable. change as necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach person-centered diagnosis or treatment goals. support to help the patient cope with the condition, sdoh need(s), and adjust daily routines to better meet diagnosis and treatment goals. knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals is G0023.