Mar 2003 Table of Contents

GETTING PAID

Defining “Confined to the Home”



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Medicare has clarified its criteria for determining whether a patient is homebound.

Fam Pract Manag. 2003 Mar;10(3):20.

One of the most perplexing aspects of certifying a Medicare patient’s home health plan of care is determining whether the patient meets Medicare’s definition of “confined to the home” (i.e., homebound). Last summer, the Centers for Medicare & Medicaid Services (CMS) attempted to clarify the matter for home health agencies. That guidance – the Medicare Home Health Agency (HHA) Manual Transmittal No. 302 (see www.cms.hhs.gov/manuals/pm_trans/R302HHA.pdf) – may benefit physicians as well. Here are the highlights:

Homebound defined

An individual does not have to be bedridden to be confined to the home. According to Medicare, a patient is considered confined to the home if his or her condition creates a “normal inability” to leave home and if leaving home would require “a considerable and taxing effort.”

Medical contraindications

CMS has said that a patient is usually considered homebound if leaving home is medically contraindicated or if the patient has a condition that restricts his or her ability to leave home without a supportive device (e.g., crutches, cane, wheelchair, walker), special transportation or the assistance of another person. The person who rarely leaves home because of feebleness and insecurity brought on by advanced age would not be considered by CMS to be homebound unless he or she meets one of the aforementioned conditions.

The following examples describe patients Medicare would determine are homebound:

  • 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 to leave home;

  • A patient who has lost the use of his or her upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave home;

  • A patient who has just returned from a hospital stay involving surgery and is suffering from resultant weakness and pain and is restricted by his or her physician to certain 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 he or she must avoid all stress and physical activity;

  • 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 or she has no physical limitations;

  • A patient in the late stages of ALS or a neurodegenerative disability.

“Excused” absences

Patients who leave the home may still be considered homebound if the absences are infrequent, for relatively short periods or for receiving medical treatment including but not limited to the following:

  • Outpatient kidney dialysis,

  • Outpatient chemotherapy or radiation therapy,

  • Attendance at adult day care centers to receive medical care.

Occasional absences from the home do not necessarily mean that the patient is not homebound. However, the nature of the absence must not indicate that the patient has the capacity to obtain health care services outside the home. Examples of absences that wouldn’t jeopardize a patient’s home-bound status include the following:

  • Attending a religious service,

  • An occasional trip to the barber,

  • A walk around the block,

  • Attendance at a family reunion, funeral, graduation or other infrequent or unique event.

According to the transmittal, the examples above are not all inclusive.

Making the determination

Finally, when trying to ascertain whether a homebound condition exists, CMS recommends evaluating the patient’s condition over time rather than for short periods during the home health stay. Doing so will give you the most accurate indication of a patient’s health status.

Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to FPM.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

Copyright © 2003 by the American Academy of Family Physicians.
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