How Medicare pays for navigation in 2024–2025

Medicare now reimburses structured care navigation delivered by trained auxiliary personnel under practitioner direction. Two complementary benefits are relevant to Aviator Health’s work with Medicare and Medicare Advantage members:

Quick comparison: PIN vs. CCM vs. PCM vs. GUIDE vs. PACE

Program	Who it’s for	What it pays for	Who bills	Typical setting	Can combine?
Principal Illness Navigation (PIN)	Medicare patients with a serious/high‑risk condition lasting ≥3 months	Time-based navigation, care coordination, person‑centered planning; peer support option for behavioral health	Practitioner who performed the initiating visit (auxiliary personnel furnish under general supervision)	Outpatient/ambulatory, incident‑to	Yes, with other care management if time/work are distinct (per AAFP/CMS PIN guidance)
Chronic Care Management (CCM)	Medicare patients with multiple chronic conditions (generally ≥2)	Non‑face‑to‑face, time‑based chronic care management and coordination	Billing practitioner (typically PCP or specialist)	Outpatient/ambulatory	Often yes, if requirements and time are separate from other services
Principal Care Management (PCM)	Medicare patients with a single serious chronic condition requiring focused management	Focused, time‑based management for one high‑risk condition	Billing practitioner managing the condition	Outpatient/ambulatory	Often yes, if distinct from CCM/PIN time and scope
GUIDE Model (Dementia)	People with dementia and caregivers (CMMI model, 2025 start)	Dementia care navigation, caregiver support, respite; model payments	Participating GUIDE organizations	Community/outpatient	Model‑specific rules; may not be combined with duplicative payments
PACE	Frail, nursing‑home‑eligible older adults who can live safely in the community	All‑inclusive medical and social services (capitated)	PACE organization	Interdisciplinary day center + home/community	Not typically combined with other Medicare FFS management codes

Notes

• PIN is a navigation benefit distinct from CCM/PCM “care management”; each has different qualifying criteria, documentation, and supervision rules. See AAFP’s PIN coding overview and RHIhub’s summary already cited on this page.

• Patient-Centered Medical Home (PCMH) is a delivery model (not a code) that often integrates CCM/PCM and, where appropriate, PIN to operationalize whole‑person care.

How Aviator fits (operational model)

• Aviator delivers navigation that aligns with Medicare’s PIN intent, while complementing existing care management (CCM/PCM) programs run by primary care, specialty clinics, or PCMH teams.

• Dedicated human navigators, supported by AI tools, provide health system navigation, benefits/authorization help, SDOH resource connection, and caregiver engagement—services squarely within PIN’s person‑centered planning and coordination scope. Aviator Home, About

• For dementia populations participating in GUIDE (where available), Aviator’s navigation capabilities parallel core GUIDE functions (education, caregiver support, coordination) and can integrate via practitioner direction and compliant workflows.

• For PACE‑eligible patients, Aviator helps families understand options and transitions; ongoing navigation is typically assumed by the PACE organization once enrolled.

• Compliance and documentation: Aviator supports practitioners with clear time/activity records mapped to the treatment plan, benefiting PIN and other care management documentation standards. AAFP and RHIhub sources on this page outline supervision and billing rules.

• Principal Illness Navigation (PIN): For beneficiaries with a serious, high‑risk condition that creates significant risk of hospitalization, decompensation, functional decline, or death. Includes a peer‑support option for behavioral health. AAFP PIN coding guidance and RHIhub summary.

• Community Health Integration (CHI): For patients whose unmet social needs (SDOH) significantly limit diagnosis or treatment. CHI is separate and can be furnished alongside PIN when requirements are independently met. See Patient Navigator Training Program policy explainer.

Billing codes for PIN (exact codes)

PIN services are billed monthly, time‑based, and reported by the practitioner who performed the initiating visit and directs care. Time must be documented and not double‑counted with other services.

Service	HCPCS code(s)	Time per month	Who furnishes the time	Key notes
Principal Illness Navigation (general)	G0023	First 60 minutes	Certified/trained auxiliary personnel (e.g., patient navigator) under practitioner direction	Incident‑to, general supervision; direct patient contact often expected.
	G0024	Each additional 30 minutes	Same as above	Add‑on to G0023 in the same month.
Principal Illness Navigation – Peer Support (behavioral health)	G0140	First 60 minutes	Certified/trained auxiliary personnel (e.g., certified peer specialist) under practitioner direction	Training should align with SAMHSA peer standards when state credentials don’t exist.
	G0146	Each additional 30 minutes	Same as above	Add‑on to G0140 in the same month.

Sources: AAFP PIN coding guidance and RHIhub PIN overview.

Who qualifies (PIN vs. CHI)

• PIN: Patient has a serious, high‑risk condition expected to last ≥3 months and requiring person‑centered planning, navigation, and substantial support (including frequent care plan or regimen adjustments, or significant caregiver assistance). Behavioral‑health PIN‑PS applies when the high‑risk condition is behavioral health. AAFP.

• CHI: Patient has SDOH barriers (e.g., housing, food, transportation) that significantly limit the practitioner’s ability to diagnose or treat problems identified in an initiating visit. CHI can be billed when those unmet needs are addressed by trained auxiliary staff under practitioner direction. Patient Navigator Training Program.

Required initiating visit (PIN)

Before PIN begins, the billing practitioner must complete an initiating visit to establish medical necessity and a treatment plan. Per AAFP/CMS policy, acceptable initiating visits include:

• Evaluation and Management (including the E/M portion of Transitional Care Management)

• Annual Wellness Visit (when performed by the practitioner who will bill PIN)

• Psychiatric diagnostic evaluation (90791)

• Health Behavior Assessment and Intervention (96156, 96158, 96159, 96164, 96165, 96167, 96168)

Excluded as initiating visits: low‑level staff‑only visits (e.g., 99211) and inpatient/observation, ED, or SNF visits. AAFP.

Supervision, personnel, and training

• Supervision: PIN (and CHI) are incident‑to services under general supervision of the billing practitioner. Auxiliary personnel may be employees, leased, or contracted. AAFP.

• Qualifications: Personnel must meet state licensure/certification where applicable. In states without such requirements, CMS expects training/competency in communication, coordination, advocacy, assessment, professionalism, and condition‑specific knowledge; for peer support, training should align with SAMHSA model standards. AAFP, PNTC explainer.

Consent, cost‑sharing, and documentation

• Consent: Beneficiary consent (verbal or written) is required annually and must be documented. Explain cost‑sharing. AAFP.

• Cost‑sharing: PIN is subject to deductible/coinsurance; many Medicare Advantage plans cover these services—verify benefits. AAFP.

• Documentation: Record minutes and specific activities tied to the treatment plan; document unmet social needs addressed and consider ICD‑10‑CM Z‑codes for SDOH. AAFP.

Program integrity and site‑of‑service notes

• One practitioner may report PIN for a given patient/month per serious condition. PIN and other care management (e.g., CCM) may be billed in the same month if time/work are distinct. AAFP.

• RHCs/FQHCs: CMS policy enables RHCs and FQHCs to bill these services beginning in 2025 under their frameworks. Confirm current rules and any clinic‑specific requirements. RHIhub.

How Aviator Health operationalizes PIN/CHI

• Covered, $0 out‑of‑pocket for most Medicare and Medicare Advantage members: Aviator’s navigation services are typically an insurance‑covered benefit. Aviator Home.

• Human navigators + AI tools: Dedicated Healthcare Navigators (nurses, care coordinators, community health workers) coordinate appointments, benefits, prior auth, and SDOH resources, with unlimited between‑visit messaging. Aviator Home, About.

• Compliance: Privacy practices are detailed in our HIPAA Notice and terms governing use in our Terms of Use.

How to refer or get started

• Clinicians and care teams: Use our intake workflow to align the initiating visit, care plan, and navigator handoff. Start here: Patient intake and scheduling. For additional referral context, see Referral information.

• Patients and caregivers: Learn about $0 out‑of‑pocket navigation for most members and enroll: Aviator Home, Sign up.

What PIN includes (common activities)

Examples (document time and link to the treatment plan):

• Person‑centered assessment and planning; care plan education tailored to goals, preferences, and culture

• Health system navigation (finding in‑network clinicians, scheduling, prior authorization support)

• Facilitating access to SDOH resources (transportation, food support, housing) when relevant

• Building patient self‑advocacy and supporting caregiver engagement

• For PIN‑PS: peer mentorship and behavioral‑health‑focused support

Policy references: AAFP PIN coding guidance; RHIhub PIN overview; PNTC Medicare navigation explainer.