Change to Homebound Status – November 19, 2013

Home bound status is changing and you need to be ready.  But is your staff and referral sources ready?

The purpose of this change is to once again reduce the availability of home health services while combating fraud.  However, due to the tightening of this restriction, you can expect that many patients who might have qualified for home health may no longer be eligible.

On November 19, 2013, the expanded home bound criteria becomes effective.  You should expect that in a few months ADRs (additional document requests) and RAC requests will begin.

The best method to survive ADRs and RAC requests is excellent documentation.  Basic, form filled, copy and pasted documentation is not acceptable.  Each note, every 485 and every communication log should be well thought out and complete. Each visit note and communication, going back to the basics, should stand alone.

If you use electronic medical records, ask your vendor to do you a favor.  Your software vendor should be able to turn off note templates.  This includes check boxes and drop down selection menus that create form sentences with little clinical or clinician customization.  While these software features save your clinicians time, they will cost you a lot of money during a RAC.

The key to this new change is that patients must meet BOTH criteria, not one or the other, but BOTH.  If the patient doesn’t meet both, you will not be able to take the patient under skilled care.

Below is the full text of the revised home bound language.

30.1.1 – Patient Confined to the Home

(Rev. 1, 10-01-03)

A3-3117.1.A, HHA-204.1.A, A-01-21

In order 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. An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.

If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. Absences attributable to the need to receive health care treatment include, but are not limited to:

  • Attendance at adult day centers to receive medical care;
  • Ongoing receipt of outpatient kidney dialysis; or
  • The receipt of outpatient chemotherapy or radiation therapy.

Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited to furnish adult day-care services in a State, shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration.

For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It is expected that 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 for nonmedical purposes, e.g., 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 the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.

Generally speaking, a patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their place of residence except with the aid of: supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated.

The revised manual instructions read as follows:

30.1.1 – Patient Confined to the Home

(Rev.172, Issued: 10-18-13, Effective: 11-19-13, Implementation: 11- 19 -13)

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. For purposes of the statute, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

1. Criteria One

The patient must either:

  1. 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

  1. 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.

2. Criteria Two

  1. There must exist a normal inability to leave home;

AND

  1. Leaving home must require a considerable and taxing effort.

If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. Absences attributable to the need to receive health care treatment include, but are not limited to:

  • Attendance at adult day centers to receive medical care;
  • Ongoing receipt of outpatient kidney dialysis; or
  • The receipt of outpatient chemotherapy or radiation therapy.

Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited to furnish adult day-care services in a State, shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration.

For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It is expected that 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 for nonmedical purposes, e.g., 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 the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.

These clarifications to “confined to the home” may lead to more restrictive applications to a Medicare beneficiary’s homebound status by the medical contractors depending on what their understanding of the definition was prior to the issuance of CR 8444.

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