"Homebound" regulation spells it out
Homebound’ regulation spells it out
To help hospital-affiliated home care agency directors keep abreast of the Medicare regulations, Hospital Home Health has abstracted the following definition of "homebound" from section 204.1 of the Medicare Home Health Agency Manual.
Another resource for regulatory information is the HCFA home page on the Internet: http:// www.hcfa.gov.
204. Conditions the patient must meet to qualify for coverage of home health services:
To qualify for Medicare coverage of any home health services, the patient must meet each of the criteria described in this section. Patients who meet each of these criteria are eligible to have payment made on their behalf for the services discussed in A7205 and A7206.
204.1 Confined to the Home.
A. Patient Confined to The Home. 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. (See A7240.l.) An individual does not have to be bedridden to be considered as 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 medical treatment. Absences attributable to the need to receive medical treatment include attendance at adult day centers to receive medical care, ongoing receipt of outpatient kidney dialysis, and the receipt of outpatient chemotherapy or radiation therapy. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving medical 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, 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 he/she has a condition due to an illness or injury that restricts his/her ability to leave his/her 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. Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists would be:
(1) a patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk;
(2) a patient who is blind or senile and requires the assistance of another person to leave his/her residence;
(3) a patient who has lost the use of his/her upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave his/her residence;
(4) a patient who has just returned from a hospital stay involving surgery suffering from resultant weakness and pain and, therefore, his/her actions may be restricted by his/her 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.;
(5) a patient with arteriosclerotic heart disease of such severity that he/she must avoid all stress and physical activity; and
(6) a patient with a psychiatric problem if the illness is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe to leave home unattended, even if he/she has no physical limitations.
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 he/she meets one of the above conditions. A patient who requires skilled care must also be determined to be confined to the home in order for home health services to be covered.
Although a patient must be confined to the home to be eligible for covered home health services, some services cannot be provided at the patient’s residence because equipment is required that cannot be made available there. If the services required by a patient 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. (See A7A7200.2 and 206.5.) However, even in these situations, for the services to be covered as home health services, the patient must be considered confined to his/her 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.
If a question is raised as to whether a patient is confined to the home, the HHA will be asked to furnish the intermediary with the information necessary to establish that the patient is homebound as defined above.
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