Clarification to Benefit Policy Manual Language on ‘Confined to the Home’ Definition

MLN Matters® Number: MM8444
Related Change Request (CR) #: CR 8444
Related CR Release Date: October 18, 2013
Effective Date: November 19, 2013
Related CR Transmittal #: R172BP
Implementation Date: November 19, 2013

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (Regional Home Health Intermediaries (RHHIs and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8444 which requires Medicare contractors to be aware of the clarification of the definition of “confined to the home” as stated in the revised section 30.1.1 of Chapter 7 of the “Medicare Benefit Policy Manual”. CR8444 clarifies the definition of the patient being “confined to the home” to more accurately reflect the definition as articulated at Section 1835(a) of the Social Security Act (the Act). In addition, the Centers for Medicare & Medicaid Services (CMS) removed vague terms, such as “generally speaking”, to ensure the definition is clear and specific.

These changes present the requirements first and more closely align the CMS policy manual with the Act. This will prevent confusion, promote a clearer enforcement of the statute, and provide more definitive guidance to HHAs in order to foster compliance.

Background
In the Calendar Year (CY) 2012 Home Health (HH) Prospective Payment System (PPS) proposed rule published on July 12, 2011, CMS proposed their intent to provide clarification to the Benefit Policy Manual language regarding the definition of “confined to the home”. In the CY 2012 HH PPS final rule published on November 4, 2011 (FR 76 68599-68600), CMS finalized that proposal. In order to clarify the definition, CMS is amending its policy manual as follows:

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 defined 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.

Additional Information
The official instruction, CR 8444 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R172BP.pdf on the CMS website.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

Source: Palmetto GBA

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