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Posts tagged ‘Homebound Status’

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.

Homebound Status

Last week, I posted about two patients who were driving but otherwise met the homebound criteria.  Your responses impressed me.  Above all, I was glad to see very few cut and dry answers and responses both sides of the fence were very convincing.   The best part was that it occurred to me that if you put that much thought into the answers, then maybe I wasn’t insane after all.

In order to be completely objective about it, I had to return to Chapter 7 of the Medicare Benefits Manual and review these patients compared to Medicare’s definition of Homebound.  Here’s the heart of the matter cut and pasted  from the manual but divided into two parts:

  1. 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.
  2. 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.

So, both patients meet the first criterion.  It is a considerable and taxing effort to leave the home.  In fact, I meet that criterion.  I live on the third floor and at least twice I week I forget something upstairs.

One patient definitely does not meet the second criterion.  Parking at the lake does is not how the patient receives healthcare or treatment and apparently this occurs ‘regularly’.

Based on the information I posted which is all I have, we cannot tell how often patient number two leaves the home.

The regs specifically address non-medical absences later in the section.  Again, this is cut and pasted directly from the manual:

However, occasional absences from the home for nonmedical 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.

Now, go read it again.  How often is occasional?  What is meant by ‘relatively short duration’ and ‘infrequent’.  Steven Wright illustrates relativity even better than Einstein when he says that everywhere is within walking distance if you have the time.

Since Medicare offers no further clarification of these definitions, we have no choice but to use the most conservative definitions and therefore, neither of these patients are confined to the home.  I was so happy with my readers that none of you were happy with just stating that they weren’t homebound.  Neither am I.

My suggestion to my client with patient number 1 was that they go out and assess him and explain to him why he should not be cooped up in a car for hours at a time.  Homebound status is the least of my concerns at the point of referral.  That would come in later after I assessed his risk of blood clots, ulcers, etc. from immobility.  If he was willing, my client through diligent nursing care and therapy could restore his functionality to the point that it would be safe again in the future.  If he was willing to comply with a treatment plan that included diet and weight loss, he could improve his life to a level he had not experienced in years.  These things are not known prior to assessment.  In fact, it is often the non-verbal language that clues us into the sincerity of the patients’ desire to comply with a care plan.

The report I received on the second patient is that he had dementia.  Dementia as a diagnosis used on home health plans of care is very poorly defined in my opinion.  Patients with early memory loss who end up on Namenda with no diagnosis of Alzheimer’s are often put into the broad category of ‘dementia’.  Dementia can mean mild confusion at times or flat out psychosis.  Furthermore, patients will often come out of the hospital with a diagnosis of Dementia that is carried over to the home health chart.  Often times, quite sane people lose it considerably in the hospital due to drugs, illness, unfamiliar environment, etc.  and get right in the head again once home. (I am re-reading this before posting.  My first inclination was to find clinical terms to replace ‘lose it considerably’ and ‘get right in the head’ but those of you who live in other states will need to know these terms should you ever decide to work in the South.)

Pretty much everyone was on target with their responses.   If the patient only has mild memory loss, he may be able to drive but will get lost and end up on Crack Alley negotiating deals for those pretty little rocks.  If he is beyond mild dementia, the police or elderly protective need to be contacted immediately.  My experience with Elderly Protective Services or whatever they are called in your community is that their scope of usefulness varies widely between communities so choose carefully.

Sadly, sometimes we are best suited to be the bad guy.  The kindest thing to do may involve being the one who is willing to go toe to toe with a patient until they surrender their car keys.  I mean that figuratively, by the way.  There are laws against assaulting patients.  We cannot take keys from patients or steal them but we can be the ones who tell the patient that we are by law obligated to report dangerous situations.  We can notify the physician and even help him draft a letter to the Department of Motor Vehicles.  Remember, the life you save may be your child’s.  And even though it is no fun, it really is okay if the occasional patient doesn’t like you because truly caring for them means making them angry.

This is what upset me and why I asked the question of you.  These two patients were referred to two separate clients in two different communities 200 miles apart.  In both instances, other agencies had refused these patients due to the fact that they were driving.

I am not at all impressed with those agencies.  Either they are much better than us in their assessment skills because they were able to make that determination without seeing the patient or they were not able to think critically and assess patients as individuals.  In nursing, there are very few black and white decisions.  Our patients are people and they are all unique and deserve consideration in these grey areas.  Even if an admit isn’t forthcoming after the initial assessment, as nurses we should look at all the assessment data and determine what is best for the patient.   If they turn out not to qualify for Medicare home health, perhaps we could find an alternative.  And no.  Medicare doesn’t pay for that but that doesn’t mean we don’t benefit from taking care of our elderly.

And so on……

Driving Me Nuts!

So, people call me.  They email me.  I get the occasional comment on my blog.  These are the ‘little things’ that make me useful to the home health community.  I am aware of what is going on at the front lines of our industry.  Usually, I can answer questions.  Sometimes, I take a while and look things up.  But sometimes, I get stumped.  that’s when I turn to y’all.

In the past several weeks, I have had calls about two patients.  Both are men.  Both have been referred to clients. The question is the same for both of them.  Do they meet the homebound status requirement?

Patient 1:

This is a man who drives a car.  Not every day but at least weekly.  It is a smaller economy car that gets ideal gas mileage.  I sincerely hope that if this were all that  you knew about the patient that you would declare him ineligible for  services in a heart beat.

However, this gentleman weighs 400 pounds.  He cannot get in the car by himself; nor can he get out of the car by himself.  He just likes to drive and sit by the lake while his wife works.  If he had to, he could drive up to the ER but then someone would have to come and get him out of the car.  Fast food is available as are banks and dry cleaners who offer in car service.  He cannot buy gas unless someone else pumps it for him, go to the MD’s office or outpatient therapy.  In fact, he was at outpatient therapy for a while.  His wife would get him in the car somehow and the therapy employees would get him out.  At some point, it was deemed to dangerous for them to do that in the black asphalt parking lot.

I have a lot of issues with this patient besides homebound status.  Blood clots seem a very real possibility.  It is rumored that he pees in a jar.  I am having a hard time imagining that he can do this without some spillage.  So, now I have immobility, acidic urine and obesity threatening this patient.  I get all that.

But, is he homebound?

Patient 2:

This patient has dementia with episodes of moderate confusion.  Like the patient above they drive.  They are not supposed to drive.  Everyone knows that this is dangerous to the patient and to the community but no one has taken his keys away from him, yet.

Again, I have real issues with this.  If the family is okay with him risking his life, that is up to them.  I am not okay with his risking someone else’s life because they don’t want to take away the car keys.  But it isn’t my feelings that we are assessing here.

I suggested that they approach the MD to get a medical restriction on his license and let him be the bad guy.  But what should happen is again, not the question.

Is this patient homebound?

What do you think?  Email me or comment below.  I will share my thoughts after I hear some of yours.

Homebound Documentation

Last week, I wrote about homebound status and I am assuming that all my readers have mastered the nuances of homebound status (even though I am still on the fence about some). But knowing your patient is homebound isn’t enough to warrant payment from Medicare and other payor sources that insist your patients be homebound. You must document it.

Bad Documentation Good Documentation
Patient SOB with exertion (Hint: even triathletes get short winded in their fifth hour.) Patient is unable to walk greater than twenty feet without rest period
Patient requires assist devices to leave home. (Does my car count as assist device?) Patient unable to ambulate without walker and requires assistance to place walker in daughters car. Cannot use public transportation.
Leaving home medically contraindicated. Patient at great risk for infection due to compromised immune system secondary to chemotherapy.
Patient unsafe to leave home due to psychiatric reasons. Patient has history of wandering into oncoming traffic. OR, patient oriented times 2.
Patient unable to drive. Physically unable to drive due to arthritis pain in hands.
Homebound due to pain in joints Patient cannot stand for greater than ten minutes due to pain in hips/knees.
Homebound due to no car Can’t help you there
Homebound due to wounds Wounds to lower extremities at great risk for infection when patient leaves home.

Reading carefully, skillful documentation of homebound status is generally speaking much longer than a simple statement. While the statements in the ‘bad’ column may actually state the homebound reason, they do not offer enough information for a third party reviewer to make an independent determination of homebound status.

As someone who reviews clinical records, I become very interested in homebound status when the following findings are evident on the clinical record:

  • Multiple missed visit reports
  • Any missed visit reports without explanation
  • A functional score of F1 or F2. If a patient can bathe, toilet, and dress themselves and require little or no assistance ambulating and transferring, why can’t they leave the house?
  • Multiple documented absences from the home regardless of where the patient went.

Again, if you look at the jobs of RACs, PSCs, and ZPICs, it is far easier to deny an entire clinical record because the patient isn’t homebound rather than read each and every note and determine if the skills are billable in the context of the patient record. If I were paid for each time homebound status was questionable, I wouldn’t be writing this blog. I would be retired and playing bingo somewhere.

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