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.
|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.