American College of Physicians: Internal Medicine — Doctors for Adults ®

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Medicare clarifies its definition of ‘homebound’

From the June 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: How has Medicare changed its definition of homebound?

A: In 2000, Congress passed a law that further clarifies the Medicare definition of homebound.

Medicare law requires that a physician certify a beneficiary as homebound before the patient is eligible to receive home health benefits. The revision to the law expands the list of circumstances in which patients can leave their home and still be classified as homebound to include participating in adult care and attending religious services.

The revised definition, which took effect in February 2001, appears below (revised text is indicated in bold):

An individual does not have to be bedridden to be considered confined to his home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving the home would require a considerable and taxing effort. Any absence of the individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial or medical treatment in an adult day-care program that is licensed or certified by the State should not disqualify an individual from being considered confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is infrequent or of relatively short duration. For the purpose of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.

The revision states that occasional absences from the home for nonmedical purposes (a trip to the barber, a walk around the block or a drive) will not necessarily disqualify a beneficiary from being classified as homebound. However, the absences must be infrequent or of a relatively short duration. Long, frequent absences indicate to HCFA that the patient has the capacity to access health care outside the home.

Generally speaking, beneficiaries will be considered homebound if they have an illness or injury that restricts their ability to leave their residence except with the aid of supportive devices (canes, wheelchairs and walkers), special transportation or another person. Beneficiaries with conditions for which leaving home is medically contraindicated are also considered homebound.

The following are examples of homebound patients:

  • Beneficiaries paralyzed from a stroke and confined to a wheelchair or requiring crutches to walk.

  • Blind or senile beneficiaries who require another person’s assistance to leave their residence.

  • Beneficiaries who have lost the use of their upper extremities and are unable to open doors, use stairway handrails, etc., and therefore require another person’s assistance to leave their residence.

  • Beneficiaries recently released from the hospital following surgery, who may be suffering from resulting weakness and pain, and whose activity is restricted by their physician to certain specified, limited activities (such as getting out of bed only for a specified period or walking stairs only once a day).

  • Beneficiaries with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity.

  • Beneficiaries with a psychiatric problem that is manifested in part by a refusal to leave their home environment or that makes it unsafe for them to leave their home unattended, even if they have no physical limitations.

Elderly beneficiaries who do not often travel from their home because of feebleness and insecurity brought on by advanced age would not meet Medicare’s criteria for homebound unless their condition is analogous to those above.

Keep in mind that you must be able to provide Medicare documentation demonstrating that the patient is homebound if it is requested.

Brett Baker is a third-party payment specialist in the College’s Washington Office. If you have questions about third-party payment or coding issues, contact him at 202-261-4533 or bbaker@acponline.org.

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