Pre-Claim Review Non-Affirmations: Homebound

Below are the top reasons of non-affirmations for not supporting homebound status:

• Documentation submitted does not support homebound criteria — one is met
• Documentation submitted does not support a normal inability to leave the home
• Documentation submitted does not support a considerable and taxing effort to leave home

Reason for Non-Affirmation
The services billed were not covered because the medical records submitted for review did not support homebound status. 

A beneficiary is considered to be homebound if there exists a condition due to illness or injury that restricts the ability to leave the place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if leaving home is medically contraindicated.

Section 1814(a) and Section 1835(a) of the Act specify that an individual is considered “confined to the home” (homebound) if the following two criteria are met:

First Criteria — One 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; or
2. Have a condition such that leaving his or her home is medically contraindicated

Second Criteria — Both of the Following Must Be Met

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

Some clinical findings that support the need for home health may include:

• Shortness of breath
• Ambulates short distances
• Unsafe ambulation due to balance issues
• Can transfer bed to chair only
• Pain interferes with ambulation/mobility
• Mental confusion
• Unable to leave home safely without assistance
• Immunocompromised

Poor Example of Homebound Status
“Homebound due to SOB with minimal exertion.”

Better Example of Homebound Status
"Upon initial examination, the patient was severely SOB from the 3 minutes it took to ambulate to the front door from the bedroom… a distance of 35 feet."

Poor Example of Homebound Status
"Unstable blood sugars.”

Better Example of Homebound Status
"FBS 250 without symptoms. Insulin dose of 18 units of 70/30 taken. BS at lunchtime was 50 and patient c/o confusion, dizziness, headache, sweating, and trembling all over and unsteady gait. States this is pattern for last week. Verbalizes concern and fear of fainting or falling.."

A high blood sugar for one day doesn't make him homebound. It is the lack of control that puts him at risk if he leaves home.

Characteristics that Raise Questions about Homebound

• No coordination or balance problems
• No need for assistive devices
• Have the ability to walk independently on even surfaces
• Independent with transportation
• Frequently go out of the home for non-medical reasons

For more information, refer to:

• 42 (CFR) Code of Federal Regulations Sections 409.42 and 424.22
• CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1 and 30.1.1 (PDF, 455.39 KB)