evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
2. Criterion Two:   - There must exist a normal inability to leave home;  AND   - Leaving home must require a considerable and taxing effort.   To clarify, in determining whether the patient meets criterion two of the homebound definition, the clinician needs to take into account the illness or injury for which the patient met criterion one and consider the illness or injury in the context of the patients overall condition.  The clinician is not required to include standardized phrases reflecting the patients condition (e.g., repeating the words taxing effort to leave the home) in the patients chart, nor are such phrases sufficient, by themsel ves, to demonstrate that criterion two has been met.  For example, longitudinal clinical information about the patients health status is typically needed to sufficiently demonstrate a normal inability to leave the home and that leaving home requires a considerable and taxing effort.  Such clinical information about the patients overall health status may include, but is not limited to, such factors as the patients diagnosis, duration of the patients condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, etc.   If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.  Ab sences attributable to the need to receive health care treatment include, but are not limited to:    Attendance at adult day centers to receive medical care;    Ongoing receipt of outpatient kidney dialysis; or    The receipt of outpatient chemotherapy or radiation therapy.
(Medicare Benefit Policy Manual)
 Attendance at adult day centers to receive medical care;    Ongoing receipt of outpatient kidney dialysis; or    The receipt of outpatient chemotherapy or radiation therapy.   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 licens ed or certified by a state, or accredited to furnish adult day- care services in a 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 an 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 be an absence of infrequent or short duration.  It is expecte d that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment.  However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.   Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists are listed below.   A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk.   A patient who is blind or senile and requires the assistance of another person in leaving their place of residence.    A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence.
(Medicare Benefit Policy Manual)
 A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence.   A patient in the late stages of ALS or neurodegenerative disabilities.  In determining whether the patient has the general inability to leave the home and leaves the home only infrequently or for periods of short duration, it is necessary (as is the case i n 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 (meeting both criteria listed above) more frequently during a short period when the patient has multiple appointments with health care professionals and medical tests in 1 week.  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 the home.   A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant weakness and pain because of the surgery and; therefore, their actions may be restricted by their physician or allowed practitioner to certain speci fied and limited activities (such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.).   A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity.    A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.
(Medicare Benefit Policy Manual)
 A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.  The aged person who does not often travel from home because of frailty and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless they meet one of the above conditions.  Although a patient must be confined to the home to be eligible for covered home health services, some services cannot be provided at the patient's residence because equipment is required that cannot be made available there.  If the services required by an individual involve the use of such equipment, the HHA may make arrangements with a hospital, SNF, or a rehabilitation center to provide these services on an outpatient basis.  (See 50.6.)  However, even in these situations, for the services to be covered as home health services the patient must be considered confined to home and meet both criteria listed above.  If a question is raised as to whether a patient is confined to the home, the HHA will be requested to furnish the Medicare contractor with the information necessary to establish that the patient is homebound as defined above.   30.1.2 - Patient's Place of Residence  (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)   A patient's residence is wherever he or she makes his or her home.  This may be his or her own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution.  However, an institution may not be considered a patient's res idence if the institution meets the requirements of 1861(e)(1) or 1819(a)(1) of the Act..  Included in this group are hospitals and skilled nursing facilities, as well as most nursing facilities under Medicaid.  (See the Medicare State Operations Manual, 2166.)
(Medicare Benefit Policy Manual)
of the Act..  Included in this group are hospitals and skilled nursing facilities, as well as most nursing facilities under Medicaid.  (See the Medicare State Operations Manual, 2166.)   Thus, if a patient is in an institution or distinct part of an institution identified above, the patient is not entitled to have payment made for home health services under either Part A or Part B since such an institution may not be considered their residence.  When a patient remains in a participating SNF following their discharge from active care, the facility may not be considered their residence for purposes of home health coverage.  A patient may have more than one home and the Medicare rules do not prohibit a patient from having one or more places of residence.  A patient, under a Medicare home health plan of care, who resides in more than one place of residence during a period of Me dicare covered home health services will not disqualify the patient's homebound status for purposes of eligibility.  For example, a person may reside in a principal home and also a second vacation home, mobile home, or the home of a caretaker relative.  The fact that the patient resides in more than one home and, as a result, must transit from one to the other, is not in itself, an indication that the patient is not homebound.  The requirements of homebound must be met at each location (i.e., the patient must meet both criteria listed in section 30.1.1 above).  A.  Assisted Living Facilities, Group Homes, and Personal Care Homes  An individual may be "confined to the home" for purposes of Medicare coverage of home health services if he or she resides in an institution that is not primarily engaged in providing to inpatients:   Diagnostic and therapeutic services for medical diagnosis;   Treatment;    Care of injured, disabled or sick persons;   Rehabilitation services or other skilled services needed to maintain a patients current condition or to prevent or slow further deterioration; or
(Medicare Benefit Policy Manual)
 Treatment;    Care of injured, disabled or sick persons;   Rehabilitation services or other skilled services needed to maintain a patients current condition or to prevent or slow further deterioration; or   Skilled nursing care or related services for patients who require medical or nursing care. If it is determined that the assisted living facility (also called personal care homes, group homes, etc.) in which the individuals reside are not primarily engaged in providing the above services, then Medicare will cover reasonable and necessary home health care furnished to these individuals.  If it is determined that the services furnished by the home health agency are duplicative of services furnished by an assisted living facility when provision of such care is required of the facility under State licensure requirements, claims for such services should be denied under 1862(a)(1)(A) of the Act.  Section 1862(a)(1)(A) excludes services that are not necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member from Medicare coverage.  Services to people who already have access to  appropriate care from a willing caregiver would not be considered reasonable and necessary to the treatment of the individual's illness or injury.  Medicare coverage would not be an optional substitute for the services that a facility is required to provide by law to its patients or where the services are included in the base contract of the facility.  An individual's choice to reside in such a facili ty is also a choice to accept the services it holds itself out as offering to its patients.   B.  Day Care Centers and Patient's Place of Residence  The current statutory definition of homebound or confined does not imply that Medicare coverage has been expanded to include adult day care services.   The law does not permit an HHA to furnish a Medicare covered billable visit to a patient under a home health plan of care outside his or her home, except in those limited circumstances where the patient needs to use medical equipment that is too cumbersome to bring to the home.  Section 1861(m) of the Act stipulates that home health services provided to a patient be provided to the patient on a visiting basis in a place of residence used as the individual's home.  A licensed/certified day care center does not meet the definition of a place of residence.  C.  State Licensure/Certification of Day Care Facilities   Per Section 1861(m)
(Medicare Benefit Policy Manual)
Per Section 1861(m) of the Act, an adult day care center must be either licensed or certified by the State or accredited by a private accrediting body.  State licensure or certification as an adult day care facility must be based on State interpretations of its process.  For example, several States do not license adult day care facilities as a whole, but do certify some entities as Medicaid certified centers for purposes of providing adult day care under the Medicaid home and community based waiver program.  It is the respons ibility of the State to determine the necessary criteria for "State certification" in such a situation.  A State could determine that Medicaid certification is an acceptable standard and consider its Medicaid certified adult day care facilities to be "State certified."  On the other hand, a State could determine Medicaid certification to be insufficient and require other conditions to be met before the adult day care facility is considered "State certified".   D.  Determination of the Therapeutic, Medical or Psychosocial Treatment of the Patient at the Day Care Facility  It is not the obligation of the HHA to determine whether the adult day care facility is providing psychosocial treatment, but only to assure that the adult day care center is licensed/certified by the State or accrediting body.  The intent of the law, in extending the homebound exception status to attendance at such adult day care facilities, recognizes that they ordinarily furnish psychosocial services.  30.2 - Services Are Provided Under a Plan of Care Established and Approved by a Physician  or Allowed Practitioner                                  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  30.2.1  Definition of an Allowed Practitioner  (Rev. 11386, Issued: 04- 27-22, Effective: 01 -01-22, Implementation: 05- 26-22)
(Medicare Benefit Policy Manual)
Allowed practitioners in addition to physicians, can certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care plan. Allowed practitioners are defined at  484.2 as a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) as defined at this part. NPs, CNSs, and PAs are required to practice in accordance with state law in the state in which the individual performs such services . Physician assistant  means an individual as defined at  410.74(a) and (c). Clinical nurse specialist  means an individual as defined at  410.76(a) and (b), and who is working in collaboration with the physician as defined at  410.76(c)(3). Nurse practitioner  means an individual as defined at  410.75(a) and (b), and who is working in collaboration with the physician as defined at  410.75(c)(3).   Individual states have varying requirements for conditions of practice, which determine whether a practitioner may work independently without a written collaborative agreement or supervision from a physician, or whether general or direct supervision and collaboration is required. In the absence of State law governing collaboration, collaboration is to be evidenced by NPs documenting their scope of practice in the medical record, and indicating the relationships that they have with physicians to deal with is sues outside their scope of practice.   30.2.  2 - Content of the Plan of Care                                                       (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  The HHA must be acting upon a physician or allowed practitioner plan of care that meets the requirements of this section for HHA services to be covered.  For HHA services to be covered, the individualized plan of care must specify the services necessary to meet the patient -specific needs identified in the comprehensive assessment. In addition, the plan of care must include the identification of the responsible discipline(s) and the frequency and duration of all visits as well as those items listed in 42 CFR 484.60(a) that establish the need for such services.   All care provided must be in accordance with the plan of care.    If the plan of care includes a course of treatment for therapy services:
(Medicare Benefit Policy Manual)
If the plan of care includes a course of treatment for therapy services:    The course of therapy treatment must be established by the physician or allowed practitioner after any needed consultation with the qualified therapist;    The plan must include measurable therapy treatment goals which pertain directly to the patients illness or injury, and the patients resultant impairments;   The plan must include the expected duration of therapy services; and    The plan must describe a course of treatment which is consistent with the qualified therapists assessment of the patients function.   30.2.3 - Specificity of Orders   (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01-11-21)   The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.   EXAMPLE 1:   SN x 7/wk x 1 wk; 3/wk x 4 wk; 2/wk x 3 wk, (skilled nursing visits 7 times per week for 1 week; 3 times per week for 4 weeks; and 2 times per week for 3 weeks) for skilled observation and evaluation of the surgical site, for teaching sterile dressing changes and to perform sterile dressing changes.  The sterile change consists of (detail of procedure).   Orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of services is provided to home health patients under a home health plan of care. When a range of visits is ordered, the upper limit of the range is considered t he specific frequency.   EXAMPLE 2:   SN x 2 -4/wk x 4 wk; 1-2/wk x 4 wk for skilled observation and evaluation of the surgical site.  Orders for services to be furnished "as needed" or "PRN" must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician or allowed practitioner order would have to be obtained.
(Medicare Benefit Policy Manual)
30.2.4 - Who Signs the Plan of Care  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  The physician or allowed practitioner who signs the plan of care must be qualified to sign the certification as described in 42 CFR 424.22.  30.2.5 - Timeliness of Signature  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   A.  Initial Percentage Payment   If a physician or allowed practitioner signed plan of care is not available at the beginning of the 30-day period, the HHA may submit a RAP for the initial percentage payment based on physician or allowed practitioner verbal orders OR a referral prescribing detailed orders for the services to be rendered that is signed and dated by the physician or allowed practitioner.  If the RAP submission is based on verbal orders, the verbal order must be recorded in the plan of care, include a description of the patient's condition and the services to be provided by the home health agency, include an attestation (relating to the physician's or allowed practitioners orders and the date received per 42 CFR 409.43), and the plan of care is copied and immediately submitted to the physician or allowed practitioner.  A billable visit must be rendered prior to the submission of a RAP. B.  Final Percentage Payment   The plan of care must be signed and dated by a physician or allowed practitioner as described who meets the certification and recertification requirements of 42 CFR 424.22 and before the claim for each 30 -day period for services is submitted for the final percentage payment.  Any changes in the plan of care must be signed and dated by a physician or allowed practitioner.  30.2.6 - Use of Oral (Verbal) Orders                                                       (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
(Medicare Benefit Policy Manual)
30.2.6 - Use of Oral (Verbal) Orders                                                       (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   When services are furnished based on a physician or allowed practitioners oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations as well as by the HHA's internal policies.  The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services.  The orders may be signed by the supervising registered nurse or qualified therapist after the services have been rendered, as long as HHA personnel who receive the oral orders notify that nurse or therapist before the service is rendered.  Thus, the rendering of a service that is based on an oral order would not be delayed pending signature of the supervising nurse or therapist.  Oral orders must be countersigned and dated by the physician or allowed practitioner before the HHA bills for the care in the same way as the plan of care.   Services which are provided from the beginning of the 60-day certification period based on a request for anticipated payment and before the physician or allowed practitioner signs the plan of care are considered to be provided under a plan of care established and approved by the physician or allowed practitioner where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care.  Services that are provided in the subsequent 60-day certification period are considered provided under the plan of care of the subsequent 60- day episode where there is an oral order before the services provided in the subsequent period are furnished and the order is reflected in the medical record.  However, services that are provided after the expiration of the plan of care, but before the acquisition of an oral order or a signed plan of care are not considered provided under a plan of care.   EXAMPLE 1: