CMS Has Clarified the HHA Definition of When a Patient is Confined to Home

CMS has clarified the term Confined to Home.

(August 26, 2014): On August 1, 2014, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 192, clarifying their definition of when a home health patient is considered to be Confined to Home as described in the Medicare Benefit Policy Manual. This clarification more accurately articulates the Homebound definition found in the Social Security Act and is intended to prevent confusion and promote greater enforcement of the statute. The homebound clarification discussed in Transmittal 192 takes effect September 2, 2014. As set out below, it is essential that you meet with your home health staff and referring physicians to better ensure that everyone in the patient care chain fully understands what it means for a patient be Homebound.

I. Clarifying the Confined to Home / Homebound Definition:

One of the eligibility requirements for Medicare coverage of home health care is that a beneficiary must be certified as “homebound.” The latest transmittal clarifies the definition of Confined to Home in section 60.4.1 of Chapter 15 of the Medicare Benefit Policy Manual (Pub 100-02). Some of the more notable parts of revised Section 60.4.1 is summarized as follows:

For a patient to be eligible to receive covered home health services, the law requires that a physician certify in all cases that the patient is confined to his/her home. For purposes of the statute, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria One:

The patient must either:

  • Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence
  • OR
  • Have a condition such that leaving his or her home is medically contraindicated.

If the patient meets one of the Criteria One conditions, then the patient must ALSO meet two additional requirements in Criteria Two below:

Criteria Two:

  • There must exist a normal inability to leave home;
  • AND
  • Leaving home must require a considerable and taxing effort.

This clarification more accurately articulates the homebound definition found at Sections 1814(a) and 1835(a) of the Social Security Act. It also brings the Manual guidance in line with the 2012 Home Health Prospective Payment System final rule that was published on November 4, 2011 (76 FR 68599-68600).

Additionally, CMS has removed vague terms such as “generally speaking” from the definition to ensure clear and specific requirements. According to CMS, these changes will prevent confusion, promote a clearer enforcement of the statute, and provided more definitive guidance to home health agencies in order to foster compliance.

II. Final Remarks:

All home health agencies should carefully review Transmittal 192 and the updated Medicare Benefit Policy Manual language. More importantly, home health agencies should educate every member in their clinical staff on the update to ensure strict compliance.

Lately, CMS has been quite active in its efforts to ensure that home health agencies are fully compliant with the Face-to-Face requirements. Nevertheless, agencies must not forget the importance of ensuring that a beneficiary is certified as homebound. This is a requirement that must be met for Medicare coverage! As a result, this clarification should assist help home health agencies in their own audit process and provide clearer guidance to both home health agencies and CMS auditors in the future.

CMS auditors will not relent in their efforts to ensure that Medicare funds are appropriately paid and that home health agencies are meeting the strict requirements for Medicare reimbursement. If you have recently experienced an audit of your records by a Medicare contractor, effective legal counsel is an effective resource that you cannot afford to dismiss. Moreover, implementing an effective compliance plan will more effectively ensure that your compliance efforts meet statutory requirements when – not if – an audit is conducted in your facility. If you need assistance with these two issues, give us a call today and we would be more than happy to assist you.

Saltaformaggio, Robert

Robert Saltaformaggio, Esq., serves as an Associate at Liles Parker, Attorneys & Counselors at Law. Liles Parker attorneys represent health care providers and suppliers around the country in connection with Medicare audits by RACs, ZPICs and other CMS-engaged specialty contractors. The firm also represents health care providers in HIPAA Omnibus Rule risk assessments, privacy breach matters, State Medical Board inquiries and regulatory compliance reviews. For a free consultation, call 1 (800) 475-1906