What Criteria Determines Whether the Patient is Confined to the Home?

In order for a patient to meet the homebound status, they must meet certain criteria.

Criteria-One:

The patient must either 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.

But wait, there is more… When your patient only meets ONE of the criteria listed above they also have to meet two additional requirements from the next section.

Criteria-Two:

There must exist a normal inability to leave home;

AND

Leaving home MUST require a considerable and taxing effort.

Sometimes patients must leave their home, this is ok IF these outings are infrequent or for short periods of time, OR if they are needed to receive other health care.  What does the need to receive other health care mean?

Attendance at adult day centers to receive medical care;

Ongoing receipt of outpatient kidney dialysis; or

The receipt of outpatient chemotherapy or radiation therapy.

Below you will find some examples that identify whether homebound status exists:

Patient paralyzed from a stroke and 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 is unable to open doors, use handrails on stairways, and requires the assistance of another individual to leave their place of residence;

A patient in the late stages of ALS or neurodegenerative disease.

A patient who has just returned from a hospital stay involving surgery who may be suffering from resultant weakness and pain and their actions may be restricted by their physician;

A patient with ASHD of such severity 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 it is considered unsafe for the patient to leave home unattended, even IF they do NOT have physical limitations.

Let’s talk about the elderly who refuse to travel because of insecurity.  These patient’s are NOT considered homebound unless they meet the above requirements.  Remember, if your MAC has questions of homebound status, your agency will be required to submit documentation and proof to establish homebound status of the patient.

Medicare Benefits Manual: 30.1.1 Patient Confined to the Home (Rev. 172, Issued: 10-18-13, Effective: 11-19-13, Implementation: 11-19-13)

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