In order to be eligible for Medicare covered home health services a patient must be considered home bound. But what does that mean? That the patient can never leave the house? Doesn’t generally leave the house? Is like a Vermonter in a snow storm, and doesn’t see the point of leaving the house?
CMS recently clarified language in its manual about what constitutes “confined to the home” and thus eligible to receive home health services. Since physicians must certify and order home health agency (HHA) services, this is relevant. The policy is found in the Medicare Benefit Policy Manual, 100-02, Chapter 7, section 30.1.1.
Here is the clarified description from the manual:
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:
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
- 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.
- There must exist a normal inability to leave home;
- Leaving home must require a considerable and taxing effort.
The policy goes on to say that the patient may leave home for medical appointments, dialysis, and for receipt of chemo or radiation therapy.
The 2019 Proposed Physician Fee Schedule Rule, released in July 2018, proposed removing the requirement for physicians to document the medical necessity of a home visit.
CMS stated that stakeholders suggested that whether a visit occurred in the office or at the patient’s home was best determined by the physician and the patient. This is only a proposal. Look for an update to this in this article in November, after the Final Rule is released.