CMS Clarifies Definition of "Confined to the Home" (Homebound) for Medicare Purposes
11/5/2013
VNAA Policy Team
Tuesday, November 5, 2013
by: VNAA Policy Team

Section: Face to Face


VNAA is carefully reviewing the Change Request 8444 recently issued by the Centers for Medicare and Medicaid Services (CMS) to contractors on the definition of homebound for the Medicare home health benefit. CMS finalized changes to the homebound definition in 2012 regulations; the implementation date for Medicare contractors is Nov. 19, 2013. A Medicare Learning Network article is also available.

VNAA is aware that this definition is extremely important for both payment and auditing reviews, and offers the following information to help clarify these changes for our members.

Background on Homebound Status

For a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician certify in all cases that the patient is confined to his/her home.  In determining whether homebound criteria are met, it is necessary to look at the patient's condition over a period of time rather than for short periods within the home health stay.

CMS makes clear that the aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless they meet the specific criteria outlined below.

Criteria for Homebound Status

CMS advises that an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria One

The patient must either:

  • Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence or
  • Have a condition such that leaving his or her home is medically contraindicated.

If the patient meets one of the Criteria-One conditions, then the patient must also meet two additional requirements defined in Criteria-Two below.

Criteria-Two:

There must exist a normal inability to leave home and leaving home must require a considerable and taxing effort.

Impact of Temporary Absence on Homebound Status

CMS Change Request 8444 also provides examples of temporary absences from the home that are acceptable for a homebound patient.  A patient could still be considered homebound if absences from the home are:

  • Infrequent
  • For periods of relatively short duration, or
  • Attributable to the need to receive health care treatment,
Absence for Health Care Treatment:

Absences attributable to the need to receive health care treatment include, but are not limited to attendance at adult day centers for the purpose of receiving medical care; ongoing receipt of outpatient kidney dialysis; or for outpatient chemotherapy or radiation therapy.

Adult Day Care Center

Regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed, certified or accredited by the State shall not disqualify an individual from being considered to be confined to his home.

Infrequent/ Short Duration:

If an absence is of an infrequent or of relatively short duration, a patient will not lose their homebound designation – including attending a religious service.

Non-Medical Absence:

In most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home such as an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if other criteria are met.

Medical Treatment Outside the Home:

Sometimes a service cannot be provided at the residence of a homebound patient because equipment is required that cannot be made available there.  If the services required by an individual involve the use of such equipment, the HHA may make arrangements with a hospital, skilled nursing facility or a rehabilitation center to provide these services on an outpatient basis.  However, even in these situations, for the services to be covered as home health services the patient must be considered as confined to home; and to receive such outpatient services a homebound patient will generally require the use of supportive devices, special transportation, or the assistance of another person to travel to the appropriate facility.

Furnishing Information to an Intermediary:  If homebound status is questioned, the CMS intermediary will request that the HHA furnish information needed to document that criteria are met. 

Examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists would be:

  • A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk;
  • A patient who is blind or senile and requires the assistance of another person in leaving their place of residence;
  • A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence;
  • A patient in the late stages of ALS or neurodegenerative disabilities.
  • A patient who has just returned from a hospital stay involving surgery who may be suffering from resultant weakness and pain and, therefore, their actions may be restricted by their physician to certain specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.;
  • A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity; and
  • A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.

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Comments (2)
Diana Staggs
12/12/2016 2:06:37 PM
In the case of a physically/mentally handicapped disabled dependent adult, would going 2/3 times a month to get groceries or go to church each Sunday per month with their mother/legal guardian disqualify said person from meeting the home bound requirements for a Home Health nurse visit? The visit is for the purpose of drawing blood for drug level screenings due to anxiety of patient and inability to have blood drawn in the doctor's office.
Also, what about a family vacation?Thank you. Diana Staggs


Lisa
11/22/2016 10:55:41 AM
what about traveling out of town for the holidays and patient is taxing effort, driving with family


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