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May 5, 2020

Determining Homebound

The Centers for Medicare and Medicaid Services (CMS) released a clearer definition of homebound to be used when deciding if patients are eligible for home health services under Medicare.

Patients are considered “confined to the home” or “homebound” if they meet these two criteria:

  1. Patients either need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or help from someone else in order to leave their home because of illness or injury OR have a condition that makes leaving the home medically inadvisable.
  2. “There must exist a normal inability to leave home; and leaving home must require a considerable and taxing effort.”

The new definition, which went into effect November 19, 2013, will prevent confusion, promote a clearer enforcement of the statute, and provide more definitive guidance to home health agencies in order to foster compliance, CMS says.

Tips to Remember:

*The designation of homebound is contingent upon a patient’s individual ability – not caregiver support. [Patients may be highly functioning due to caregiver assistance.]

*Homebound does not mean bedbound.

Homebound criteria applied to psychiatric patients:

*Illness is manifested by a refusal to leave the home (e.g., severe depression, paranoia, agoraphobia).

*Due to illness it would be unsafe for the patient to leave the home (e.g., hallucinations, violent outbursts).

NOTE: Psychiatric patients may have no physical limitations.

Documentation of Homebound Status

Documentation from the certifying physician's medical records and/or the acute/post-acute care facility's medical records is used to support the certification of home health eligibility. This documentation must support the patient's need for skilled services and homebound status.

The home health agencies documentation, such as the initial and/or comprehensive assessment of the patient can be incorporated into the certifying physician's medical record and used to support the patient's homebound status and need for skilled care. For additional information, refer to the "FTF Documentation" section on the CGS "Home Health Face-to-Face (FTF) Encounter" Web page.

The home health agency should document the homebound status frequently enough to reflect the beneficiary's current functional status, and at a minimum, at least once per episode.

It is recommended that homebound status be documented in clear, specific, and measurable terms.

Documentation of the homebound status needs to be clear throughout care.

Whether stated or implied, the homebound status must be obvious from a reviewer's standpoint.

Documentation Tips

Documentation of homebound status "fits" entire medical record. All homebound documentation on the Plan of Care (POC) must be supported by documentation in the medical record. If the POC shows "endurance" is the reason the beneficiary is homebound, the documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records should state why or how the limited endurance makes the beneficiary homebound.

Example: The beneficiary can only walk 10 feet before becoming extremely short of breath and diaphoretic at which time the beneficiary needs to rest. In addition, the beneficiary needs to hang onto furniture while walking.

Simply documenting the use of a cane or walker in the POC does not reflect the homebound status. Many beneficiaries who use a cane or a walker are not homebound. Documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records should reflect how the medical condition restricts the ability to leave home.

Example: The beneficiary must use a quad cane while ambulating even short distances in the home, and even then, has a very slow, unsteady gait. At times, the beneficiary requires the assistance of another to get up and moving safely.

Pay special attention to documentation if the beneficiary is homebound secondary to Alzheimer's disease or other mental illness. Early stages of these disease processes may not support homebound status based solely on the diagnosis code. Therefore, documentation in the certifying physician's medical records and/or the acute/post-acute care facility's medical records should clearly reflect why it is unsafe for the beneficiary to leave the home unsupervised, even if the beneficiary has no physical limitations.

Example: The beneficiary is unable to leave home due to psychotic symptomatology (e.g., auditory and visual hallucinations). These symptoms are of such nature and severity that it would be considered unsafe for the beneficiary to leave home without assistance.

Medicare considers the beneficiary homebound if BOTH the following requirements are met:

  1. the assistance of another person or the use of an assistive device – crutches, wheelchair, walker
  2. It is difficult to leave home and he/she is unable to do so

A homebound patient may still leave the home for the following without putting his/her homebound status at risk:

  • medical treatment
  • religious services
  • attend a licensed or accredited adult day care center

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