Determining Homebound Status
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Defines criteria and documentation requirements used by OrthoNet/Optum to determine whether a patient is homebound for purposes of home health skilled services (physical and occupational therapy); applies to all in- and out-of-network programs and provider types where utilization review for home health services is performed.
No material clinical or coverage changes in this revision.
Coverage Criteria — Homebound Determination
Homebound Criteria (CMS-based)
Covered when ALL of the following are met
Based on CMS criteria cited in policy.
Patient must ordinarily be unable to leave home without considerable effort.
Short walks or short drives may be considered appropriate non‑health related absences if infrequent/short.
Skilled Care and Medical Necessity Requirements
Covered when ALL of the following are met
Document that level of complexity/sophistication requires licensed professional (APTA, CMS).
If lack of progress occurs, document reasons and justification for continued skilled treatment.
Include initial exam/evaluation, prognosis/plan of care, and follow‑up progress reports as appropriate.
Absences from the home that are frequent or of an extended duration may negate homebound status. The policy clarifies that short or infrequent non‑health related absences can be acceptable; for example, a walk around the block or a short drive may be considered appropriate non‑health related absences when they are brief and not routine.
Services that can be self‑administered or that can be provided safely and effectively by an unskilled person or caregiver without the direct or general supervision of a licensed provider are not considered skilled services and therefore are not medically necessary as skilled home health services.
Provider Actions & Documentation Requirements
Utilization review applies across all programs
Utilization review determinations for home health services are rendered for all in-network and out-of-network programs; the treating provider may be asked to provide information to meet the homebound definition.
No step therapy process
This policy does not include a step therapy process for home health skilled therapy services — step therapy is not applicable.
Document longitudinal clinical evidence of homebound status
Document longitudinal clinical information that demonstrates the patient's normal inability to leave home and that leaving home would require a considerable and taxing effort; include diagnosis, duration, clinical course, prognosis/plan of care, nature and extent of functional limitations, therapeutic interventions and results, and appropriate objective tests and measures with initial exam, evaluation, plan of care, and follow-up progress reports as needed.
- Include diagnosis, duration, clinical course, prognosis, and functional limitations.
- Record initial examination, objective tests/measures, evaluation, plan of care (goals, frequency, duration), and progress reports.
- Explain how absences are infrequent or short duration when applicable.
Denial risk for insufficient documentation of skilled necessity
Failure to document that services are reasonable and necessary or that the required skilled services must be performed by a licensed professional may lead to denial of home health skilled therapy services.
- Show that skilled care requires professional skill, complexity, or sophistication not safely provided by an unskilled person.
- Provide objective reassessments comparing current and prior measurements to demonstrate expected improvement or justification for continued skilled care.
Key Definitions
Background & Clinical Context
Home health skilled services are most commonly used for patients who are elderly with multiple impairments in activities of daily living (ADLs) or instrumental ADLs (IADLs), those who live alone, or those with limited informal support; non‑elderly patients with significant medical, surgical, or disabling conditions may also qualify. Coverage requires that the treating provider document medical necessity, functional limitations, and that the required skilled care can only be safely and effectively provided by a licensed professional, with objective reassessments demonstrating expected significant improvement or justification for maintenance/prevention of decline.
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