CMS issues transmittal that explains new criteria for homebound status

Home health agencies must soon start providing more specific details about patients’ health status, mobility and lack of independence to justify homebound status. Beginning next month, two sets of criteria will be applied to determine whether a patient falls under this category, according to a new CMS transmittal. The guidance also removes vague terms such as “generally speaking” to ensure that the requirements that must be met to apply the definition are clear and specific, CMS explains.

The transmittal, which covers patients who receive covered home health services under both Part A and Part B, has an implementation date of Nov. 19. The new guidance is contained in change request 8444, which CMS issued on Oct. 18.

The new criteria are likely to create headaches for home health agencies, some experts suggest.

The new language is crafted to force agencies to identify why patients’ conditions make it difficult for them to leave their homes, explains Arlene Maxim, founder of Troy, Mich.-based A.D. Maxim Consulting. “Initially the language will lead to more denials.”

The changes could present some unanticipated problems, says attorney Liz Pearson of Pearson & Bernard in Edgewood, Ky. For instance, a person suffering dementia may be able to leave home under criteria two, “but it certainly is contraindicated,” she says.

Note that criteria two is worded as normal inability to leave the home and a considerable and taxing effort, Robert Markette an attourney with Hall Rendor, Killian Heath & Ledger points out. The patient must meet the description in both parts of the second element as well as the support/assistive device or medically contraindicated prong of element one. Agencies should be sure that their documentation on the patient makes each element clear.

New criteria contains high level of detail

Patients must meet one of two descriptions in the first set of criteria and both of the descriptions in the second set. The two new sets of criteria for determining homebound status are as follows:

Criteria One

Patients must either:

Due to illness or injury, need to use supportive devices, such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person to leave their place of residence

OR

Have a condition that would make leaving their homes medically contraindicated.

Patients who meet one of the two requirements described above must also meet the both of the following:

Criteria Two

There must exist a normal inability to leave home;

And

Leaving home must require a considerable and taxing effort.

Patients who leave the home may be considered homebound if they are taken to receive health care treatment, CMS explains. Trips for health care treatment can be but are not limited to travel to adult day centers to receive medical care, and treatment involving outpatient kidney dialysis or outpatient chemotherapy or radiation therapy. Such trips may also be taken to participate in a state-licensed therapeutic, psychosocial or medical treatment in an adult day-care program.

Homebound patients can also take infrequent or brief trips for some nonmedical reasons such as to attend a religious service, a funeral, graduation or other infrequent or unique event, or short trips to a barber, or a brief casual walk or drive, CMS says.

Examples of homebound patients

The transmittal provides several examples of patients who would meet these criteria. They include patients who are:

• Paralyzed by a stroke and are wheelchair-bound or need crutches to walk;
• Blind or senile and need another person’s assistance to leave their home;
• Have lost use of their upper extremities and need help from someone else to open doors or use handrails;
• Are in the stages of amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease, or has neurodegenerative disabilities. Determining whether the patient has a general inability to leave home and leaves home only briefly or rarely must involve an examination of the patient over time, not during short periods within a home health stay.
• Have recently been discharged from the hospital after surgery and are suffering post-operative weakness and pain and, whose normal activities (moving from bed, walking) are restricted by their physicians;
• Have arteriosclerotic heart disease severe enough to need to avoid stress and physical activity; or
• Have a psychiatric illness that manifests in their refusal to leave home or makes it unsafe for the patient to leave home unattended, even if they do not have physical limitations.