HOME HEALTH- Medicare Requirements
"Homebound" does NOT mean that a patient has to be "bed bound" to qualify. The patient is considered "homebound" under Medicare if:
| First Criteria
One of the following must be met: |
Second Criteria
Both of the following must be met: |
| 1. Because of illness or injury, the individual needs the aid of supportive devices such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person to leave their place of residence (which can be home, assisted living, adult family home, etc.). | 1. There must exist a normal inability to leave home. |
| 2. Have a condition such that leaving his or her home is medically contraindicated. | 2. Leaving home must require a considerable and taxing effort. |
The patient can leave home for medical treatment (such as chemotherapy or dialysis) or for receiving therapeutic and psychosocial treatment (such as through a certified adult day care program).
The patient cannot be disqualified from services if they leave home for a non-medical absence as long as the absence is "infrequent and short in duration." Some examples include attending a religious service, a trip to the barber or special family event.
The patient must have a "skilled need" that requires the skills of a licensed nurse, speech therapist, or physical therapist to perform.
Once a skilled need is established, a secondary discipline such as medical social worker, home health aide, or occupational therapist may be involved in providing patient services.
Medicare will NOT pay for personal care services (aka home care) in the absence of a skilled need.
Medicare requires a progress note from a Face to Face visit that includes medical conditions related to the need for Home Health AND clinical findings which support the patient's "homebound" status.
Clinical findings that support a patient's "homebound" status:
- Unsteady gait, frequent falls, poor balance
- Assistance of two or more persons to ambulate or transfer
- Dyspnea at rest
- Unable to leave home due to mental confusion
- Medically contraindicated due to recent surgery
- Medically contraindicated due to infected, draining, or complicated wound
- Medically contraindicated due to immunosuppressant/serious risk of infection
- Confined to a wheelchair requiring assistance or supportive device
- Confined to a wheelchair requiring maximum assistance with ADLs
- Dyspnea with ambulation greater than 10 feet
Medical conditions that support a "skilled need" for Home Health:
- New meds, patient requires further teaching and assessment
- Deconditioned due to hospitalization, requires skilled services
- Wound requiring skilled care
- History of falls, problems with poor balance, gait instability
- Infection requiring IV therapy
- Indwelling urinary catheter requiring assessment, maintenance and teaching
- Acute respiratory insufficiency requiring cardio-pulmonary assessment and teaching
Things to look for when referring to Home Health
Shows signs of weakness
Falls frequently or is a fall risk
Has pressure ulcers or needs wound care
Has increased or uncontrolled pain and/or is in need of pain management
Has confusion with medication
Needs teaching or education for a new diagnosis:
Information Needed for New Referrals
- Current demographics information (primary contact phone and address)
- Insurance information
- Current medications list
- Qualifying Face-to-Face encounter with referring provider:
- Progress note from a Face-to-Face visit that includes medical conditions related to the need for Home Health AND clinical findings which support the patient's homebound status. Progress note should answer the question: Why Home Health? Why Now?
- Specific Home Health orders:
- Must be signed by MD, DO, DPM, PA or NPP
- If wound care, please include specific wound care orders
HOSPICE- Referring Your Patients
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A patient is eligible for Hospice care if two Physicians, usually the PCP and the Eden Hospice Medical Director, determine that the patient has a prognosis of six months or less to live if the disease runs its natural course.
Signs and Symptoms that may indicate decline and need for hospice care
Multiple hospitalizations/frequent ER visits
Progressive weight loss
Decreasing appetite
Dysphagia
Increased weakness or fatigue
Decline in cognitive status
Increasing pain, increasing difficulty managing pain
Increasing dyspnea
Recurring infections
Information Needed for New Referrals
- Current demographics information (primary contact phone and address)
- Insurance information
- Current medications list
- Recent progress note and reason for referral
If you have any doubt about whether the requirements for Hospice care have been met, please contact us for a Hospice informational visit.