Homebound?

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Specializes in COS-C, Risk Management.

I'm having a disagreement with my DoN about whether a patient is considered homebound. My understanding of the Medicare guidelines is that it must take a "taxing effort" for the patient to leave the home. He is under 25, no assistive devices, no exertional dyspnea, and is able to drive a vehicle without modifications. I say he doesn't fall in the homebound category. She has decided that as long as he's not driving himself (regardless of capability) that he qualifies as homebound. Second issue is that the pt doesn't have any residual weakness from hospitalization. Fatigue, yes. Weakness, no. Nothing a good couple of nights of sleep wouldn't fix. Doesn't need PT or OT to "recover."

I've worked for two different HHAs that have been indicted for Medicare fraud. I'm not aiming for a third. What say you home health nurses?

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Not Homebound!!! Now does he have medicare and if so, why does he have medicare?

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Specializes in COS-C, Risk Management.

Yes, he has Medicare due to a pulmonary illness of genetic origin. :-)

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what are you guys seeing him for? what skill are you performing at your visits? not only does this man need to be homebound, he also has to have a skilled need for services........ and he must have been scored independent for bathing, dressing, light meal prep, med management... that means the agency can't be getting reimbursed much for him. why bother?:confused:

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Specializes in COS-C, Risk Management.

Infusion therapy and management of portacath is our skilled service, but pt is known to be non-compliant with tx (still has IV meds from the last time we were there).

The why bother is the part that I can't figure out. I know the DoN is desperate for visits, but I don't see the skill for Medicare here. Pt administers his own antibiotics and says that he's able to manage the portacath himself.

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Yeah. we had a pt like that on service with us once. we discharged him to an infusion clinic for portacath management. he was already administering his own tpn, i think it was. you guys should definitely be discharging this guy for not "homeboundness" (not a word, i know :wink2: ) as well as non-compliance. there is no skill here.....:uhoh3:

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Specializes in COS-C, Risk Management.

I agree with you wholeheartedly, but the DoN was giving me grief yesterday. I know that there's wiggle room in some of the rules and regs, but this is not a wiggle-able situation, IMHO. I think this is going to end up a case that I don't get paid for, sadly. That's two hours out of my day that I won't get back.

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You may want to review the criteria defined by CMS as leaving home must be infrequent and of short duration. It is allowed to go for a drive or short walk as long as it is infrequent and of short duration, to a medical appointment or religious service or to adult day care.

http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_adp.php?p_faqid=9070&p_created=1207329475

The Benefit Policy Manual (Internet-Only Manual 100-02, Chapter 7, Section 30.1.1) explains in detail what it means to be homebound. While we have excerpted portions below, please see the manual for full details.

"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."

A patient's homebound status is not violated by attendance of religious services or attendance at a State licensed, State certified, or State accredited medical adult day care center.

"Occasional absences from the home for non-medical 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."

In addition to the information given in our Benefit Policy Manual, we have also addressed this question in a response to an inquiry back in April of 2003. We responded to the query with the following information:

"Homebound status is determined on an individual basis, looking at the patient as a whole. If the net effect of driving indicates that the individual has the capacity to get their health care routinely outside of the home, then it could challenge their eligibility. The fact that a patient is fit enough to drive raises questions as to whether the basic statutory requirement is met. Because individual circumstances can vary greatly, necessitating determinations on a case-by-case basis, we are reluctant to issue a specific policy that relates to driving in every possible occurrence. Inherent in such a policy would be judgments about the particular circumstances under which it may be appropriate for an individual to operate a motor vehicle. We believe that such determinations must continue to be made on a case-by-case basis."

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