CGS Initiates a Widespread Home Health Probe on Face-To-Face Encounter Documentation

As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers.  The topic code for this review will be 52xxT (‘xx’ denotes various numbers) and the edit will select start of care home health claims equally across the provider community.  Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity compliance with all CMS coverage guidelines, correct billing and coding.

In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. The Centers for Medicare & Medicaid Services (CMS) clarified the “face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes.” (CMS FAQ # 44)

The previous was from CGS website: http://bit.ly/18czZ7g. Site goes into additional details of examples of what should be included and what would be considered insufficient within FTF documentation. The site also recommends actions for agencies to prepare for this edit which will come in the form of an Additional Documentation Request (ADR) letter. They recommend:

1. Checking for claims in the Additional Development Request status/location in the Fiscal Intermediary Standard System (FISS) at least weekly.
2. Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
3. Mailing your documentation for claims selected to CGS by day 30.

Defining Homebound

With many conflicting ideas,  interpretations, and vague guidance, determining if a patient is homebound can often be challenging.

Some will automatically assume a patient is not homebound if they hear they drove or left the house. But this isn’t necessarily true. A December 2010 survey we conducted to test home care professionals knowledge of homebound confirmed this notion. We found many people jumped to the conclusion that a patient was not homebound if they left the house for any reason or drove. 

Home care professionals are doing patients a disservice by not knowing the proper homebound definition. With a clearer understanding of what it is, patients can get the care they really need.

We shared Medicare’s specific homebound definition previously on our blog here. In summary, just because a patient leaves the house, or even drives, it does not mean they are not homebound. For one, any excursions related to medical appointments or religious activities cannot be taken in consideration  to a patient’s homebound status. Also, it says that a person is homebound if leaving “requires a considerable and taxing effort.” So perhaps they did drive to the grocery store, but if it took them 30 minutes to get into the car and needed the assistance of a friend or relative, they may be homebound.

The problem arises is how do you prove a “considerable and taxing effort”? The answer is documentation. Instead of saying it was difficult for a patient to get around the house, you can be more specific and say the patient was “unable to ambulate more than 100 feet without having to rest.” Its all opinions until you give quantities and specifics and even then you may still have a patient who is on the fence because there are not specific guidelines on what physical limitations qualify  someone homebound There will be some judgment calls. But with documentation which quantifies the physical or sometimes mental limitations you then have  proper documentation to back it up your decision.

Understanding homebound status will not only help us provide better care for in-need patients, but it will also save money in the long run. For example, if a patient is disqualified from homebound status, then they must leave the house frequently to receive all care and/or they miss critical appointments, which can cause them to take a downturn and end up in a hospital or nursing home. This would be much more expensive than if they got their care in the home and were able to heal there.

If you still have questions about homebound status, please contact us at nick [at] daymarck.com.

Medicare Home Health Homebound Definition

One of the most common questions we get asked is: "How do you define "homebound?" If this is a question you have, review the below information sheet put together by CEO Nick Dobrzelcki to set the record straight. If you still have questions after reading the info sheet, please contact us at nick [at] daymarck.com.

Homebound Definition

     The statutory language (effective December 21st, 2000) clarified and broadened the homebound eligibility criterion in two ways:

1. Absences attributable to the need to receive health care treatment, including regular absences to participate in therapeutic, psychosocial, or medical treatment at a licensed or accredited adult day-care program, will not disqualify a beneficiary from being considered homebound.
2. Absences for the purpose of attending a religious service are deemed to be absences of infrequent or short duration. (Generally a beneficiary whose absences from the home are not considered infrequent or of short duration will not be considered to be homebound.)

The Current Homebound Definition in the Medicare Act reads as follows:

     An individual shall be considered to be “confined to his home” if the individual has a condition:

     • due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive devise (such as crutches, a cane, a wheelchair or a walker),
     • or if the individual has a condition such that leaving his or her home is medically contraindicated.
 
     While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be “confined to his home”. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to an absence of infrequent or short duration. [42 U.S.C. 1395n(a)(2)(F)] 
_______________________________________
 

U.S. Health and Human Services Secretary's clarification to Medicare's homebound definition: Directs providers to be more flexible in order to protect beneficiaries 

On July 26, 2002 Tommy Thompson, Secretary of the United States Department of Health and Human Services, issued a press release and changes to the Medicare Home Health Agency Manual. The Secretary directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria. This is important to elders and disabled Medicare beneficiaries as an individual must be confined to home (homebound) in order to qualify for Medicare home health coverage.

In particular, the Medicare Home Health Agency Manual, §§204.1-204.2, was amended to include additional, not all inclusive examples of situations in which the homebound criteria is met. (Family reunion, funeral, graduation.) More importantly, the following general language was added to the Manual:

It is necessary (as in determining whether skilled nursing services are intermittent) to look at the patient's condition over a period of time rather than for short periods within the home health stay. For example, a patient may leave the home (under the conditions described above, e.g. severe and taxing effort, with the assistance of others) more frequently during a short period when, for example, the presence of visiting relatives provides a unique opportunity for such absences, than is normally the case. So long as the patient's overall condition and experience is such that he or she meets these qualifications, he or she should be considered confined to home. (Emphasis added)

While the new language does not really add to the already existing homebound criteria, it does provide important direction that the criteria are to be applied flexibly and with a broad view of the patents’ condition. Advocates should use the Secretary’s press release language and the manual language to help make these points when clients are erroneously denied coverage.

CMS’ policy about the homebound status of home health patients who can drive

Just the fact that a patient drives does not automatically make them ineligible for homecare services. They issued clarification in 2008 which many providers do not follow. Within the clarification they specifically wrote:

“Homebound status is determined on an individual basis, looking at the patient as a whole. If the net effect of driving indicates that the individual has the capacity to get their health care routinely outside of the home, then it could challenge their eligibility. The fact that a patient is fit enough to drive raises questions as to whether the basic statutory requirement is met. Because individual circumstances can vary greatly, necessitating determinations on a case-by-case basis, we are reluctant to issue a specific policy that relates to driving in every possible occurrence. Inherent in such a policy would be judgments about the particular circumstances under which it may be appropriate for an individual to operate a motor vehicle. We believe that such determinations must continue to be made on a case-by-case basis.”

Question 2: Medicare home health patient who drives

Determining homebound status is not as easy as it seems. This is in part to CMS's broad and non-specific definition. Most people within the homecare industry can recite that Medicare homecare patients have to have the condition "that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort." After this, there is definite discrepancy in what this exactly means.

As far as driving, this fact does not automatically exclude a patient from home health services. CMS answered a Q&A in 2008 to this effect. The bigger picture has to be looked at.

Question 2 does not indicate if there is a considerable and taxing effort to leave the home thus the correct answer would be not enough information to make a decision.