Homebound status, which Medicare calls "confined to the home," is a two-criteria test. The patient must need a device, special transportation or another person to leave home, or have a condition that makes leaving medically contraindicated; and on top of that, they must have a normal inability to leave home and leaving must take a considerable and taxing effort. Medicare pays for home health only when both criteria are met and the chart shows why.
This is the clinician's version. If you want the patient-facing explanation of all four Medicare requirements, that is in who qualifies for home health care. This page is about making the determination at the kitchen table and writing it down so it survives a records request.
Every quotation below is from the Medicare Benefit Policy Manual, chapter 7, section 30.1.1, unless another source is named.
Who Decides What
There are two determinations, and conflating them is the first mistake.
| Who | Does what | Source |
|---|---|---|
| The certifying physician or allowed practitioner | Certifies that the patient is confined to the home, as part of the home health certification | 42 CFR 424.22(a)(1) |
| The agency's assessing clinician | Determines homebound status, and documents it, at the initial assessment visit and again at the comprehensive assessment, for Medicare patients | 42 CFR 484.55(a)(1) and (b)(2) |
The physician's signature does not make the patient homebound. It says the physician believes they are. The agency still has to find it, in the home, and write down what it found. If the contractor asks, the manual says "the HHA will be requested to furnish the Medicare contractor with the information necessary to establish that the patient is homebound." That request goes to you, not the physician.
Criterion One: Why Leaving Is Hard
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."
Three details clinicians miss:
- "Because of illness or injury." The device or the help has to be needed because of a medical condition. A patient who takes a cane on walks for confidence does not meet criterion one on the cane alone.
- "In order to leave their place of residence." The test is leaving the home, not moving around inside it. A patient who walks the hallway unaided but cannot manage the front steps without a person is describing criterion one exactly.
- Medically contraindicated includes psychiatric illness. The manual's examples include "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."
Meeting criterion one gets you to the second gate. It does not finish the test.
Criterion Two: Normal Inability and Taxing Effort
Both of these must be true:
"There must exist a normal inability to leave home; AND leaving home must require a considerable and taxing effort."
The manual tells you how to think about it: "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 patient's overall condition." It also tells you to look over time, not at one visit. For a patient with late-stage ALS, it says "it is necessary ... to look at the patient's condition over a period of time rather than for short periods within the home health stay," and that a week of multiple appointments does not undo homebound status "so long as the patient's overall condition and experience is such that he or she meets these qualifications."
"Normal inability" is the usual state. "Taxing effort" is what it costs the patient when they do go: the help needed, the recovery afterward, the symptoms it provokes. Both are things you can describe.
Warning
The manual on stock phrases: "The clinician is not required to include standardized phrases reflecting the patient's condition (e.g., repeating the words 'taxing effort to leave the home') in the patient's chart, nor are such phrases sufficient, by themselves, to demonstrate that criterion two has been met." A checkbox that says "homebound: yes" and a note that says "taxing effort" is the chart that fails a review.
The Absences That Are Allowed
A patient who leaves the home can still be homebound. The manual sorts absences into three groups.
| Kind of absence | Rule | Examples in the manual |
|---|---|---|
| For health care treatment | Never disqualifies, "including regular absences" | Adult day centers for medical care, outpatient dialysis, outpatient chemotherapy or radiation; adult day-care programs "licensed or certified by a state, or accredited" |
| Religious services | "Shall be deemed to be an absence of infrequent or short duration" | Any religious service |
| Anything else | Allowed "if the absence is of an infrequent or of relatively short duration" | "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" |
The sentence that ties the third group together is the one to remember. Those nonmedical absences do not break homebound status if they "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."
That last clause is the real test. A patient who gets to the grocery store every other day with the same effort it would take to get to an outpatient clinic is telling you something about whether home health is necessary at all.
Worked Cases
These follow the manual's own examples and the three-group rule. They are illustrations of how the criteria read, not CMS rulings on any specific patient.
A woman three days home from a hip replacement. Walker, one-person assist on the three porch steps, surgeon's instructions limit her to short periods out of bed. Criterion one: device and assistance. Criterion two: she cannot normally leave, and when she does it costs her. The manual lists exactly this patient: "a patient who has just returned from a hospital stay involving surgery ... restricted by their physician or allowed practitioner to certain specified and limited activities." Homebound, and the chart should say what the restrictions are and for how long.
A man with COPD who goes to dialysis three times a week by medical transport. Criterion one: special transportation. Criterion two: dyspnea on minimal exertion, needs a day to recover after each trip. The dialysis absences are health care treatment and do not count against him. Homebound.
A woman with moderate dementia whose daughter drives her to a licensed adult day program four days a week. Criterion one: assistance of another person. The manual's examples include "a patient who is blind or senile and requires the assistance of another person in leaving their place of residence." Criterion two has to be shown in its own right: what happens when she leaves, and why she cannot do it alone. The day program is a licensed adult day-care absence and is allowed. Homebound if criterion two is documented, and the documentation is the part that gets questioned.
A man who still drives to church on Sunday and the barber once a month, with a cane. Religious services are deemed infrequent or short by law. The barber is an "occasional trip to the barber." Neither disqualifies him. The question is criterion one and criterion two: does he need the cane because of illness or injury to leave, and is there a normal inability with a taxing effort? If he drives himself to those places without difficulty, criterion two is probably not met, and the cane alone does not carry criterion one. The manual's myth, and the one patients ask about most, is that driving decides it. It does not. The effort does.
A 91-year-old who rarely leaves because she is frail and nervous about falling, with no specific diagnosis driving it. The manual answers this directly: "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." Not homebound on these facts. If she has a gait disorder, a fracture, severe arthritis or heart failure that is the reason for the frailty, document that condition and go back to criterion one.
A man with severe agoraphobia and no physical limitation. Criterion one by medical contraindication: the manual's psychiatric example, a refusal to leave home or a condition where leaving unattended is unsafe. Criterion two: describe the normal inability and what an attempt to leave does to him. Homebound, with a psychiatric basis that has to be in the chart.
What the Chart Has to Say
The manual lists the kind of information that demonstrates criterion two: "the patient's diagnosis, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, etc." That is a documentation template.
| Element | What to write | Weak version |
|---|---|---|
| Criterion one, which one | The device, transport or person needed, tied to the diagnosis; or the contraindication | "Uses walker" |
| Normal inability | How often the patient leaves, and for what | "Homebound" |
| Taxing effort | What leaving costs: assistance, time, symptoms, recovery | "Taxing effort to leave home" |
| Course and prognosis | Getting worse, stable, improving; expected trajectory | Blank |
| Functional limits | Ambulation distance, stairs, transfers, endurance, cognition, as measured | "Weak" |
| Allowed absences | Name them and the group they fall in | Unmentioned, then discovered by the contractor |
Tip
Practice, not rule: re-ask the homebound questions at every comprehensive assessment, not only at the start of care, and write a new answer rather than carrying the old one forward. The patient who was homebound after surgery in week one may not be in week seven, and a recert that repeats the admission note is the pattern reviewers look for. The OASIS-E2 Guidance Manual's general rule applies: data at each time point should be "based on a unique patient assessment, not simply carried over from a previous assessment."
Where Homebound Is Not the Question
Two situations where clinicians argue about homebound when the rule is elsewhere:
- The patient lives in a facility. A patient's residence is "wherever he or she makes his or her home," including a relative's home or a home for the aged. But a hospital or a skilled nursing facility cannot be a residence for home health purposes, and neither can most Medicaid nursing facilities (section 30.1.2). That is a place-of-residence question, not a homebound one.
- The patient needs equipment that cannot come to the home. The agency can arrange outpatient delivery of that service at a hospital, SNF or rehab center, and the patient still has to be homebound for the services to be covered as home health. Needing the equipment does not make them not homebound.
A homebound determination with a reason behind it
Logicly records the agency's homebound determination at start of care, resumption and recertification with the criterion that applies and a clinical narrative, flags a Medicare chart that is missing one, and will not let the assessment be signed without it.
Key Takeaways
- Two criteria, in order. Criterion one is why leaving is hard. Criterion two is that the patient normally cannot, and that it costs them when they do. One option from the first, both parts of the second.
- The physician certifies. The agency's clinician determines and documents, at the initial visit and the comprehensive assessment.
- Health care absences never count against the patient. Religious services are deemed short. Everything else is fine if infrequent or brief and it does not show the patient could get care outside the home.
- Age and frailty by themselves are not a criterion. A diagnosis behind the frailty is.
- Stock phrases do not document anything. Diagnosis, duration, course, prognosis, measured limits and what has been tried do.
Frequently asked questions
What are the two homebound criteria?
Criterion one: because of illness or injury the patient needs a supportive device, special transportation, or another person's help to leave home, or leaving home is medically contraindicated. Criterion two: there is a normal inability to leave home, and leaving requires a considerable and taxing effort. A patient must meet one option in criterion one and both parts of criterion two.
Can a homebound patient leave the house?
Yes. Absences for health care treatment never disqualify a patient, including adult day care programs licensed or certified by the state, dialysis, chemotherapy and radiation. Religious services are deemed infrequent or short by law. Other absences are fine if they are infrequent or of relatively short duration, such as a trip to the barber, a walk around the block, a drive, a funeral, a graduation or a family reunion.
Who decides whether a patient is homebound?
Two people, with two different jobs. The certifying physician or allowed practitioner certifies that the patient is confined to the home. The agency's assessing clinician determines homebound status at the initial assessment visit and again at the comprehensive assessment, and documents the clinical basis for it.
Is writing 'taxing effort to leave the home' enough to document homebound status?
No. The Medicare Benefit Policy Manual says clinicians are not required to use standardized phrases, and that such phrases are not sufficient by themselves. The chart needs longitudinal clinical information: diagnosis, how long the condition has lasted, its course, prognosis, the nature and extent of functional limitations, and what has been tried.
Is a frail elderly person who rarely leaves home automatically homebound?
No. The manual is explicit that an aged person who does not often travel from home because of frailty and insecurity brought on by advanced age is not considered confined to the home unless they meet one of the criterion one conditions. Age and reluctance are not a criterion.
Sources
- CMS, Medicare Benefit Policy Manual, Chapter 7, Home Health Services, section 30.1.1 "Patient Confined to the Home" (Rev. 10438) and section 30.1.2 "Patient's Place of Residence." Every quotation above is from the current chapter, fetched from cms.gov.
- 42 CFR 409.42(a): confined to the home as a condition of coverage.
- 42 CFR 424.22(a)(1): the physician or allowed practitioner certification.
- 42 CFR 484.55(a)(1) and (b)(2): the agency determines eligibility, including homebound status, at the initial assessment visit and the comprehensive assessment.
- CMS, OASIS-E2 Guidance Manual, section 1.5.5 (assessment at each time point is a unique assessment).
- Related on this site: who qualifies for home health care, referral to first visit.