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Confined to the Home


Here’s the point of this entire post.  Medicare knows the definition of ‘homebound’.   Medicare states that patients don’t have to be bedridden but there must exist a normal inability to leave the home and that when the patient does leave the home it requires a taxing effort.

As it turns out, most of us and quite a few physicians also know the definition and write it verbatim on visit notes, care plans and face-to-face documents.  When Medicare documentation calls for ‘reason homebound’, they are not asking for their own definition.

So, here’s my way of avoiding those pesky denials related to homebound status and overturning the ones that do get denied.  At the time of admission or recertification document all of the reasons why the patient can’t just up and go and all contributing factors.

These are very incomplete lists but I always try to support homebound status with as many factors as are applicable to the patient.

Absolutes Supporting Reasons
Severe pain with ambulation multiple medications that can impair balance
Safety concerns due to recent hx of multiple falls. multiple meds that can impair judgment
Disoriented to person and place and must be supervised at all times urinary incontinence
Short of breath while talking, eating or repositioning in bed cumbersome assist devices
SaO2 drops to 87 with activity apprehension about leaving home
Unable to ambulate safely s/p hip replacement moderate pain after standing for extended periods
Impaired judgment secondary to psychiatric illness cannot open some doors, drive or use left arm to balance due to splint
High risk of infection due to open wound and compromised immune system. requires considerable effort communicate needs clearly due to residual aphasia and paralysis of dominant hand.

 

Note the difference between the Absolutes and Supporting reasons.  People are not considered confined to the home because of apprehension alone but it adds depth to a complete picture of a patient with severe pain when ambulating.

Patients short of breath while talking or eating who are also incontinent and rely upon an assist device to get to the restroom are at very high risk for falls.

Documenting all assessment findings that contribute to homebound status at least once an episode and then continuing to support these reasons in your visit notes may very well get you paid.

486 Summary Example:  Patient homebound due to hip replacement two weeks ago and cannot walk without another person assisting him with his walker.  He is taking narcotic pain medications which increases his risk for falls and there are steps without a bannister leading to the front door.

The truth is that we all meet Medicare’s definition of homebound status at times.  Isn’t it hard for you to leave the house in the morning?  Surely it is a taxing effort for you to make sure all the kids have their lunch and homework, find your keys, retrieve your cell phone from the litter box where the toddler put it and somehow make it to the car.  If a normal inability does not include four trips to the car and back to house to retrieve forgotten items including the baby, then crazy is the new normal.

Medicare doesn’t care about any of that. They want to know, from a clinical perspective, how the patients meet the criteria they set forth for us in the conditions of participation.  We need to paint a crystal clear picture and not just write enough to meet guidelines.  When you are finished documenting homebound status, there should be no question that the patient cannot and does not leave the home.

If there is a question, go take a second look.  If you cannot elaborate on ‘SOB with exertion’ (as I am after climbing 6 flights of stairs), your patient may very well not be homebound.

Of all the wild excuses for denials lately, this one is not so unreasonable.  We can do this without changing the law, involving physicians, and praying that the grammar police don’t get us.

Good luck.  I am very confident we can take this denial off the table.

15 Comments Post a comment
  1. Mandy Estes #

    If only we could get the physicians to document homebound this way….

    Like

    February 19, 2014
    • Copy the list and give to your Docs. I’m sure you can add even more to it. For a small fee, I will sign it, ‘love, Julianne’.

      Like

      February 19, 2014
  2. well said

    Like

    February 19, 2014
    • thanks for the kind words.

      Like

      February 19, 2014
  3. Ann #

    Great Job on getting the word out! Thanks for giving everyone some solid examples.

    Like

    February 19, 2014
    • Thanks! High praise coming from you, Ann.

      Like

      February 19, 2014
  4. elisan fitch #

    Julianne, I enjoy and look forward to your blog. You have made many regulations (and other things) so much more clear and understandable for me. I will be printing this and taking it to the doctors (and their staff)….I will even recommend they sign up for you blog….

    Like

    February 19, 2014
    • Thank you so much. If I clarify one or two things for you that allow you devote more time to patient care and actually get paid for it, it is well worth my while. Tell your docs they can not only sign up for the blog but they can also contribute if they so desire by sending an email or writing a post on what they love and hate about home health. Never mind. We know what they hate. Maybe about how we could be of better service to their patients.

      Like

      February 19, 2014
  5. sharon1755 #

    I am a faithful reader and this is one of your best. Thanks for the great examples!

    Like

    February 19, 2014
    • Sharon,

      It’s late and I have a headache and I really, really needed those kind words. Thank you.

      Like

      February 19, 2014
  6. Nicole Winslade, RN #

    Excellent post, easily one of the best you’ve written – and you’ve written some good ones. I’ve cut and pasted it into a note on my desktop, that’s how much I expect I’ll be using it! Thank you so much.

    Like

    February 23, 2014
    • Nicole, thanks so much! Share with Jan and tell her hello.

      Like

      February 23, 2014
      • Nicole Winslade, RN #

        So, here’s how it’s changed. Last week, I would have written, “Pt. experiencing weakness s/p fall at home with closed head injury, concussion, multiple contusions and abrasions. Pt. homebound d/t residual weakness, requires assistance to ambulate, unable to safely go out of home unassisted and dependent on adaptive device (wheelchair).” (You’re snoring already, right?)

        Here’s what I’m turning in on my Summary Worksheet today: “Pt. experiencing weakness s/p fall at home with closed head injury, concussion, multiple contusions and abrasions. Pt. is homebound d/t safety concerns after recent hx of fall with injury and hospitalization with restraints. He is unable to ambulate 10 feet even with 2 person assist. He needs two person assist to stand from wheelchair and has a high risk of infection due to metastatic lung cancer with radiation and corticosteroid treatments. Urinary incontinence and increased hearing loss in R ear with long term total hearing loss in L ear increase his risk for falling again, according to the Fall Risk Assessment.”

        Sooooooo much better! (If I do say so myself.)

        Like

        February 24, 2014
        • You may say so yourself. You’ve come a long way!

          Like

          February 25, 2014
  7. sahily #

    Julianne, we need more blogging on homebound and “taxing effort” 😀
    Love reading your posts!!!
    Hugs, Sahily

    Like

    December 23, 2015

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