NCODA Supports Integrated Oncology Teams with Patient Navigation Tools & Education
In cancer care, access to timely and effective treatment is critical. However, patients often face significant challenges when navigating the health care system. They may struggle to manage communication among providers, juggle multiple appointments, and understand and adhere to complex treatment plans.
These challenges – which can lead to delayed care, unmet health needs, and poorer overall health outcomes – are most acute in underserved populations who experience adverse social determinants of health, such as limited education, unstable housing, and lack of transportation.
Professional oncology navigators play a crucial role in identifying and addressing these challenges, removing treatment barriers, improving access to care, enhancing understanding, and supporting informed decision making.
As part of its mission to support medically integrated oncology care teams, NCODA (Network for Collaborative Oncology Development & Advancement) offers a range of services for professional oncology navigators, including guidance on overcoming operational challenges and tools to help clinicians better support patients, their families, and caregivers.
Mary Anderson
“NCODA’s priority is for patients to have timely access to care and stay on their treatments throughout their entire regimen without falling through the cracks,” said Mary Anderson, BSN, RN, OCN, Senior Manager of Nursing Membership & Professional Development, NCODA. “Professional oncology navigators help to improve access to care by identifying care barriers ahead of time and finding ways to mitigate them.”
Principal Illness Navigation Codes Acknowledge Importance of Professional Cancer Navigation
As noted in a 2025 NCODA White Paper, despite strong evidence linking the support of navigation services with superior patient outcomes, practices were historically unable to bill for them, limiting the expansion of the professional navigator role. In January 2024, the Centers for Medicare & Medicaid Services (CMS) recognized the importance of professional navigation services and their positive impact on patient outcomes. As a result, CMS added navigation services performed by professional navigators to the Physician Fee Schedule, enabling reimbursement through the creation of Principal Illness Navigation (PIN) billing codes.
“Prior to the CMS PIN code ruling, professional navigation was a relatively new concept to most cancer clinics,” Anderson said. “Because clinic leaderships didn’t understand the role and it was not reimbursable, it was looked at as a ‘free service.’ Even those who appreciated its potential value to patients couldn’t justify the man hours.”
Anderson pointed to the introduction of value-based care models as the first step in linking professional cancer navigation to the high-quality care needed to prevent emergency department visits and hospitalizations – two key metrics CMS measures as part of value-based care. The introduction of PIN billing codes sealed the deal, with many commercial insurers following CMS’s lead and introducing comparable reimbursement policies.
Caprina Tomlinson
“The introduction of CMS PIN codes was a significant leap forward for the profession,” said Caprina Tomlinson, RN, OCN, ONN-CG, NCODA member and Oncology Nurse Navigator at Robert Wood Johnson Cancer Center in Belleville, New Jersey. “In the real world, economics matter, and knowing that our services are not a financial burden for the Center or the patients we treat gives me a strong voice on my integrated care team. More importantly, it gives our patients a voice.”
Advancing Reimbursement Success
To help cancer centers overcome operational challenges with principal illness navigation, NCODA offers a White Paper, Advancing Reimbursement Success. The White Paper includes comprehensive information and guidance covering:
- Qualifying for PIN services
- Patient-centered activities of principal illness navigation
- PIN reimbursement code details
- How to document PIN services
- Strategies to help ensure that navigation programs can fully leverage billing opportunities
One of the top challenges the White Paper addresses is team engagement. It notes that successfully guiding a patient through their cancer journey requires collaboration across the interprofessional care team. When providers, billing staff, or administrators lack understanding of the navigation process and its value, it can result in missed billing opportunities and gaps in patient care. Anderson noted that the complexity of oncology treatments – multi-modality regimens delivered by different providers and departments – demands this team engagement approach.
“Leadership buy-in was critical when I defined and built our professional navigation service,” Tomlinson added. “It allowed me to formally delineate the navigator’s role and gave me the leverage needed to demonstrate the program’s value to providers, hospital administration, and patients. Plus, it provided the foundation and support to educate everyone in the Center about the benefits of navigation services.”
Another strategy the White Paper advises is to follow CMS guidelines for patient consent, which require that patients give written or verbal consent before receiving navigation services and must be informed of potential cost-sharing responsibilities.
Additional challenges and potential solutions outlined in the White Paper include:
- Timing of initial provider visit
- Documentation complexity
- Coding complexity
Bringing Clarity to Every Treatment Journey
One of the newest navigation tools NCODA offers to its members is a web-based Patient Treatment Calendar builder, which makes it easy to create and share personalized care schedules to help patients, their families, and caregivers visualize and follow their treatment schedule. The calendars can be populated with schedules for medications, checkups/visits, tests and scans, treatments/procedures, educational information, and other resources.
The tool allows clinicians to keep care plans up to date as treatments evolve. It can be accessed at any time, from any device. Clinicians can store all their patient calendars in one centralized location, and they can save time and streamline workflows by reusing and adapting calendars for future patients.
Calendars can be printed or shared with patients and other providers via secure links from text, email, or QR code. They are easily viewed on smart phones and mobile devices, placing important information right at hand.
According to Anderson, the Patient Treatment Calendar Builder tool was viewed by over 20,000 people and used by more than 6,000 in its first two months.
“Patients appreciate being able to see and make sense of very complex treatment regimens,” she said. “It helps to reduce their treatment-related anxiety, makes them more compliant with treatment protocols, and gives them a sense of control and empowerment.”
Navigating the Complexities of Oral Anticancer Medication Regimens
Because caring for individuals taking oral anticancer medications (OAMs) presents unique challenges for both patients and health care professionals, NCODA collaborated with the Oncology Nursing Society to develop resources to assist practices in navigating the care of patients taking OAMs.
The OAM Care Compass is a comprehensive collection of tools designed to help practices analyze their processes, design effective workflows, enhance patient education, and improve outcomes through standardized, high-quality care.
“When a patient is taking oral therapies, there are many opportunities for them to fall through the cracks,” Anderson said. “The OAM Care Compass fills those gaps with an interprofessional workflow that addresses the entire treatment lifecycle, from planning and education to patient support for side effects, help accessing and refilling medications, financial assistance, and more.”
NCODA members use the OAM Care Compass to share best practices with others in their clinic as well as with other clinics, ensuring that workflows and analyses are well optimized. The program includes:
- A Positive Quality Intervention (PQI) resource that outlines the steps practices can take to analyze their current workflow and create an interprofessional process that promotes seamless, efficient, and patient-centered care.
- A Workflow Analysis Tool to help practices assess their current OAM program by highlighting key points for workflow development and recommending expert intervention strategies.
- Resources for OAM patient and caregiver education, including an OAM checklist and additional tools to support the care of patients taking OAMs.
- A Specialty Pharmacy & Patient Assistance Contact Directory to help clinicians organize specialty pharmacy contacts and patient assistance program (PAP) details to promote continuity of care, timely treatment initiation, and patient safety.
- An OAM Adherence Blueprint with the latest validated scales and strategies.
The Future of Patient Navigation
Anderson and Tomlinson are bullish about the future of professional oncology navigation, especially as treatment regimens get more complex and more patients fall into the “underserved” category.
“More people than ever are in need of professional navigation,” Anderson said. “And more clinicians than ever are starting to appreciate the ability of patient navigators to take on some of their burden and control complex situations that others in the clinic cannot.”
“Professional navigators add important light to the shadows that providers often don’t have the time or nuanced understanding to decode,” Tomlinson concluded. “It’s an exciting and rewarding field and I’m honored to be part of its growth.”
