Homebound or not?
This is a question that is often the topic of discussion at many home health therapy offices.
Most home health therapists are fairly seasoned when it comes to making decisions on whether or not a patient is homebound but there is indeed somewhat of a grey area as well. We compiled data from the CMS regulation with the TWO criteria and some examples on when a patient can be considered confined to the home:
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Patient Confined to the Home
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
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.
2. Criteria Two:
There must exist a normal inability to leave home;
AND
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
receivehealth 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 daycare 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. Some examples
of homebound patients that illustrate the factors used to determine whether a homebound condition
exists are listed below.
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.
In determining whether the patient has the general inability to leave the home and leaves the home
only infrequently or for periods of short duration, it is necessary (as is the case in determining whether
skilled nursing services are intermittent) to look at the patient’s condition over a period of time rather
than for short periods within the home health stay. For example, a patient may leave the home
(meeting both criteria listed above) more frequently during a short period when the patient has
multiple appointments with health care professionals and medical tests in 1 week. So long as the
patient’s overall condition and experience is such that he or she meets these qualifications, he or she
should be considered confined to the home.
•
A patient who has just returned from a hospital stay involving surgery, who may be suffering from
resultant weakness and pain because of the surgery 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
•
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.
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 one of the above conditions.
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 an individual involve the use of such equipment, the
home health agency may make arrangements with a hospital, SNF, or a rehabilitation center to provide these services
on an outpatient basis. (See §50.6.) However, even in these situations, for the services to be covered as
home health services the patient must be considered confined to home and meet both criteria listed
above.
If a question is raised as to whether a patient is confined to the home, the home health agency will be requested to
furnish the Medicare contractor with the information necessary to establish that the patient is
homebound as defined above.
References: https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/downloads/bp102c07.pdf
page=36&zoom=auto,88,527
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c07.pdf
page=72&zoom=auto,88,30630.1.1
