RE: Homebound restrictions

[Guest guest]

:

Please find below the exact Medicare definition for the homebound status, copied

from the Medicare Home Health Benefit Manual (HIM-11). You will note the

section highlighted in yellow.

Hope this is of help.

Jean-Michel Geoffriau, PT, Director of Rehabilitation

Sta-Home Health and Hospice

406 Briarwood Drive, Bldg. 200, , MS 39206

JGEOFFRIAU@...

(ext. 8173) office

mobile

e-fax

START

Medicare Benefit Policy Manual

Chapter 7 - Home Health Services

30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health

Services

(Rev. 1, 10-01-03)

A3-3117, HHA-204, A-98-49

To qualify for the Medicare home health benefit, under §§1814(a)(2)© and

1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following

requirements:

Be confined to the home;

Under the care of a physician;

Receiving services under a plan of care established and

periodically reviewed by a physician;

Be in need of skilled nursing care on an intermittent

basis or physical therapy or speech-language pathology; or

Have a continuing need for occupational therapy.

For purposes of benefit eligibility, under §§1814(a)(2)© and 1835(a)(2)(A) of

the Act, " intermittent " means skilled nursing care that is either provided or

needed on fewer than 7 days each week or less than 8 hours of each day for

periods of 21 days or less (with extensions in exceptional circumstances when

the need for additional care is finite and predictable).

A patient must meet each of the criteria specified in this section. Patients who

meet each of these criteria are eligible to have payment made on their behalf

for services discussed in §§40 and 50.

30.1 - Confined to the Home

(Rev. 1, 10-01-03)

A3-3117.1, HHA-204.1

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.

Some examples of homebound patients that illustrate the factors used to

determine whether a homebound condition exists would be:

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 (under the conditions described above, e.g., with

severe and taxing effort, with the assistance of others) more frequently during

a short period when, for example, the presence of visiting relatives provides a

unique opportunity for such absences, than is normally the case. 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 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; and

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 HHA

may make arrangements with a hospital, skilled nursing facility (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 as confined to 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 requested to furnish the intermediary with the information necessary to

establish that the patient is homebound as defined above.

END

From: PTManager [mailto:PTManager ] On Behalf Of

jcohen135

Sent: Saturday, September 10, 2011 2:08 PM

To: PTManager

Subject: Homebound restrictions

My business provides outpatient therapy to seniors in senior centers and

sometimes in the patients' homes under Medicare part B. I have noticed a trend

that some seniors who frequently attend events at the senior centers state that

they are currently receiving home health therapy services. My area is dominated

by one major HH provider and I have inquired about their homebound policies to

no avail. Has anyone else dealt successfully with similar situations, or has the

definition of " homebound " become so lax that the patients still qualify for HH

even if they regularly go out for social events at the senior center?

Thanks for any input.

Cohen PT, MS

Mobile Rehab LLC