Medicare Guidelines for Home Health Services

First, the patient must meet the Medicare definition of "HOMEBOUND": An individual does not have to be bedridden to be considered as confined to home. The condition of the patient should be such that there exists a normal inability to leave home, and that it would be a considerable and taxing effort for the patient to leave home. The absences from home should be of short duration and infrequent or to receive health care treatment such as chemotherapy, radiation, outpatient dialysis, and/or day care for medical care. Day care services must be certified or licensed by the state. Non-medical absences from home include beauty or barbershop, family reunion, funeral, graduation, and/or any other unique event. This would not necessitate a finding that a patient is not homebound. If these absences occur, they must be infrequent and of short duration and with a taxing effort. If a patient is able to drive, they are considered able to obtain medical care.

 

SKILLED NURSING Medicare defines three primary nursing functions that it considers to be "skills" and therefore reimbursable by Medicare:

Observation and Assessment	Teaching and Training	"Skilled" Procedures
of patient conditions including, but not limited to:	needs including, but not limited to:	including, but not limited to:
New Diagnosis	Medications	IV Infusions
Exacerbated Diagnosis	Medication Regimen	IM/SQ/ID Injections
Fluctuating Vital Signs	Specified Procedures	Insulin Injections
Weight Changes	- Injections	Calcimar Injections
Edema	- Intermittent       Catheterization	Catheter Changes
Symptoms of Drug Toxicity	- Wound Care	Wound Care
Respiratory Changes	- Diabetic Care	Tube Feedings
Circulatory Changes	- Ostomy Care	NP/Trach Suctioning
Initiation of Medical Gasses	External/Pareneral Feedings	Heat Treatments
Post-hospital Follow-up	Bowel/Bladder Training	Ostomy Care, with associated complications

 

PHYSICAL THERAPY may be indicated if the level of need is such that intervention by a trained therapist is required, if:

The patient has difficulty

• Getting in/out or repositioning in bed
• Walking inside or outside
• Standing/Sitting
• Going up or down steps
• Getting on/off toilet or bedside commode

The patient has

• A history of falls
• Shortness of breath with activity
• Poor safety awareness
• A need for related teaching or training
• Contractures or pressure areas
• Equipment needs
• Limited ROM, decreased sensation or strength
• A decline in function due to stroke, pain, arthritis, amputation, etc.

 

OCCUPATIONAL THERAPY may be indicated if the skills of a trained therapist are needed by the patient who has:

• Difficulty in performing Activities of Daily Living (ADL's; dressing, grooming, bathing, feeding...) or safely completing mobility tasks
• Poor coordination
• Difficulty in performing housekeeping or cooking chores
• Limited use of arms or hands
• Sensory loss
• Shoulder pain
• A need for adaptive equipment
• Decline in function
• Memory problems or problem-solving deficits

(NOTE: Occupational Therapy does not qualify to be the only "skilled" service, at the start of home health services.)

 

SPEECH THERAPY may be indicated if the skills of a trained therapist are required by the patient who has:

• A voice disorder
• A speech articulation disorder
• Dysphagia
• A language disorder
• Aural rehabilitation needs
• Non-oral communication needs

 

MEDICAL SOCIAL SERVICES may be indicated if the patient's social, emotional or economic situation impacts their ability to recover or to reach maximum rehabilitation potential. Need must be at a level requiring the intervention of a trained social worker for:

• Assessment of social and emotional factors
• Counseling for long-range planning and decision-making
• Education about or assistance in accessing Community Resources
• Short-term counseling

(NOTE: Medical Social Services does not qualify as a "skill", and cannot stand as the only home health service.)

 

HOME HEALTH AIDE Services can be provided to patients who require assistance with ADL's if the patient is also receiving care from a "qualifying" skilled professional. Home Health Aide services include:

• Assistance with bathing and grooming
• Assistance with transfers/ambulation
• Assistance with exercises
• Assistance with light housekeeping and meals may be provided incidental to the visit for personal care