Home Health Eligibility
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Homebound Status

A Medicare beneficiary must be confined to the home in order to use their Medicare home health benefit. CMS defines homebound status in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.1.1. It states a physician or allowed NPP must certify that the patient is 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 conditions listed under Criteria One above, then the patient must ALSO meet two additional requirements as defined in Criteria Two below.

  1. Criteria Two
    • There must exist a normal inability to leave home;

      AND
    • Leaving home must require a considerable and taxing effort.

In determining whether the patient meets criterion two of the homebound definition, the clinician needs to take into account the illness or injury for which the patient met criterion one and consider the illness or injury in the context of the patient’s overall condition.

The clinician is not required to include standardized phrases reflecting the patient’s condition (e.g., repeating the words “taxing effort to leave the home”) in the patient’s chart, nor are such phrases sufficient, by themselves, to demonstrate that criterion two has been met. For example, longitudinal clinical information about the patient’s health status is typically needed to sufficiently demonstrate a normal inability to leave the home and that leaving home requires a considerable and taxing effort. Such clinical information about the patient’s overall health status may include, but is not limited to, such factors as the patient’s diagnosis, duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, etc.

  • Documentation in the certifying physician/NPP medical records and/or the acute/post-acute care facility’s medical records will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined.
  • The certifying physician/NPP and/or the acute/post-acute care facility medical record for the patient must contain information that justifies the referral for Medicare home health services. Documentation to support patient eligibility and support certification can most often be found within clinical progress notes and discharge summaries.

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Posted 8/13/2024