OASIS Alert

Published on Wed Aug 17, 2005 PDF

'Considerable and taxing' may not be enough.

Remember to check and document homebound status, or you risk more than wasted OASIS assessment time - you could forfeit the entire episode payment.

Claims are commonly denied when patients have low clinical severity and are highly functional on the OASIS assessment - such as in Health Insurance Prospective Payment System (HIPPS) code HAEJ1 - reports Cahaba GBA in its June 1, 2005 Medicare A Newsline. Missed visits because the patient wasn't home also may result in denial if the documentation doesn't adequately explain the reason, the regional home health intermediary says.

Homebound Status is Individual, Subjective

Issue: Despite all the changes that came with the prospective payment system and the OASIS assessment, some things are the same. One of these is the requirement that the patient be homebound to qualify for the Medicare home health benefit. If the patient doesn't qualify, Medicare won't pay the agency for the episode.

When assessing homebound status, the central issue is still "whether it takes considerable and taxing effort to leave home and if the absences are infrequent," stresses consultant Terry Cichon, with FR&R Healthcare Consulting Inc. in Deerfield, IL.

Example: A patient who is wheelchair bound and lives in a one-story home with ramps may be able to leave home without a considerable and taxing effort. But the same patient in a third floor walk-up apartment with no elevator is definitely homebound, Cichon says.

OASIS Questions Can Support Homebound Status
 
What to do: To avoid having your claim denied after you provide the care, know what to look for to prove homebound status:

1. Is the patient home? Even if the patient is not in his own house or apartment, he could be considered to be at home, explains the Centers for Medicare & Medicaid Services in the Medicare Benefit Policy Manual. An assisted living facility, group home or relative's home also qualifies, CMS says. A hospital, skilled nursing facility or nursing facility does not.

2. Is it hard for the patient to leave home? Medical conditions that restrict ambulation, contagious diseases, major wounds or immunosuppression requiring reverse isolation all can support homebound status. Vision problems, weakness, cognitive limitations and severe heart or respiratory disease also may limit the patient's ability to leave home.

Tip: Many of the OASIS assessment questions provide clues to potential homebound status. For example, answers that indicate the patient is bedfast on M0690 (Transferring) or answers showing the need for assistance in M0700 (Ambulation/Locomotion) can help support the clinician's assertion that the patient is homebound, experts suggest.

3. If it is hard, but the patient leaves home, ask how often and why? Patients can be homebound and still leave home for medical care. Infrequent and short absences to attend religious services or major family events such as weddings, graduations or funerals also don't disqualify patients, says Cahaba. And a trip to the hairdresser or barbershop is allowed, the RHHI says.

Adult day care is also an acceptable reason for leaving home, reminds RHHI Associated Hospital Service. But the home health agency is responsible for validating that the day care is a state licensed or certified facility, AHS stresses in its explanation of medical review criteria.

Heads up: The patient must be attending adult day care for therapeutic, psychosocial or medical reasons, not just for socialization or "babysitting," Cichon warns. And even when the patient leaves home for acceptable reasons, leaving must still require taxing effort and documentation must reflect this, Cahaba says.

Avoid Documentation Denials

In medical review, homebound status is determined "on an individual basis according to the documentation provided," Cahaba warns. You must document it in the medical record at least once during the episode, and "frequently enough to reflect the beneficiary's current functional status," the RHHI adds.

Besides documenting the reasons the patient qualifies at the beginning of the episode, continue to reinforce these reasons with ongoing evidence, especially as the patient makes progress in therapy, instructs consultant Linda Rutman with Charlotte, NC-based LarsonAllen Health Care Group. And make sure the documentation is consistent from one clinician to another, she adds.

Throughout the episode, use clear, specific and measurable information, such as "becomes short of breath after 10 feet" instead of "fatigues easily," Cahaba illustrates. Make homebound status obvious to the reviewer, the RHHI instructs.

Caveat: Even if leaving home requires considerable and taxing effort, if the patient chooses to leave home frequently for non-medical reasons, the beneficiary could be considered not homebound, Cahaba warns. 

Note: Find AHS' medical review criteria at www.ahsmedicare.com/provider/toolbox/pdf/HHA%20MRC.pdf. An expert panel report linking OASIS answers to homebound status is at http://aspe.hhs.gov/daltcp/reports/OASISfr.htm#chapIII. CMS' policy manual is at www.cms.hhs.gov/manuals/102_policy/bp102index.asp.