Page 143 - Business Development Orientation Binder

EXAMPLES OF CMS ACCEPTABLE DOCUMENTATION TO JUSTIFY HOMEBOUND STATUS

Note both Criteria-One and Criteria-Two must be completed.

Criteria-One: Describe what assistive devices the patient is dependent on (if any) & specifically why the patient's
condition warrants special transportation or the assistance of another person OR describe the condition that makes
leaving home medically contraindicated:
• Patient is temporarily homebound secondary to right total knee arthroplasty and currently walker dependent
with limited painful ambulation

• Patient is unable to ambulate on uneven surfaces, is high fall risk and requires use of a four wheel walker
• Patient is paralyzed from recent stroke and is unable to ambulate safely, requires wheelchair for home mobility

• Patient is blind and/or senile, requires the assistance of another person when leaving place of residence
• Patient is homebound due to pain limiting ability to ambulate safely and independently, is currently wheelchair

dependent

• Patient is homebound due to shortness of breath when ambulating greater than 20 feet, unsteady gait and
requires a four wheel walker making it a great effort and taxing to leave their home
• Patient had several recent falls in the home requiring physical therapy services to evaluate for assistive devices

for safety and gait training. Patient is homebound due to significant leg pain and unsteady gait

AND

Criteria-Two: Describe why the patient has a normal inability to leave home and why leaving home must require a
considerable and taxing effort:
• Patient is homebound due to advanced dementia, poor safety awareness and high fall risk
• Patient is homebound due to recent hospitalization for pneumonia and is short of breath when walking short
distances, unsteady gait, and unable to ambulate without assistance of another person
• Patient just returned from hospital stay involving surgery, is suffering from resultant weakness and pain.
Physician has restricted and limited patient's activities such as getting out of bed for short periods of time,
walking stairs only once daily
• Patient is homebound due to severe leg pain secondary to even slight exertion following recent falls at home

Does NOT support homebound status if used alone:

• Confusion, unable to get out of the home alone • Homebound per CMS guidelines (need specifics)
• Weak, unable to drive, frail • Unable to leave home due to Fx hip/surgery
• Unable to safely leave home unassisted • Dependent upon adaptive devices
• Poor ambulation/ fall risk • Medical restrictions
• SOB upon exertion • Requires assistance to ambulate