Workers Comp Zone


The proposed new chronic pain regulations (which are in a 15 day comment period that expires as of December 19) would include the following section on home health care services (shown in italics):

“Recommended on a short-term basis following major surgical procedures or in-patient hospitalization, to prevent hospitalization, or to provide longer- term nursing care and supportive services for those whose condition is such that they would otherwise require inpatient care.

Home health care is the provision of medical and other health care services to the injured or ill person in their place of residence.

Home health services include both medical and non-medical services deemed to be medically necessary for patients who are confined to the home (homebound) and who require one or all of the following: 1). Skilled care by a licensed medical professional for tasks including, but not limited to, administration of intravenous drugs, dressing changes, occupational therapy, physical therapy, speech-language pathology services, and/or 2) Personal care services for health-related tasks and assistance with activities of daily living that do not require skills of a medical professional, such as bowel and bladder care, feeding, bathing, dressing and transfer and assistance with administration of oral medications, and/or (3) Domestic care services such as shopping, cleaning, and laundry that the individual is no longer capable of performing due to the illness or injury that may also be medically necessary in addition to skilled and/or personal care services. Domestic and personal care services do not require specialized training and do not need to be performed by a medical professional (ACMQ, 2005) (Ellenbecker, 2008).A prescription or request for authorization for home health services must include justification for medical necessity of the services. Justification for medical necessity requires the physician’s documentation of: =

(1) The medical condition that necessitates home health services, including objective deficits in function and the specific activities precluded by such deficits; (2) The expected kinds of services that will be required, with an estimate of the duration and frequency of such services; and
(3) The level of expertise and/or professional licensure required to provide the services.
Homebound is defined as “confined to the home”. To be homebound means:

  • The individual has trouble leaving the home without help (e.g., using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of the occupational illness or injury OR
  • Leaving the home isn’t recommended because of the occupational illness or injury AND
  • The individual is normally unable to leave home and leaving home is a major effort (CMS, 2014).

    Evaluation of the medical necessity of home health care services is made on a case-by-case basis. For home health care extending beyond a period of 60 days, the physician’s treatment plan should include referral for an in-home evaluation by a Home Health Care Agency Registered Nurse, Physical Therapist, Occupational Therapist, or other qualified professional certified by the Centers for Medicare and Medicaid in the assessment of activities of daily living to assess the appropriate scope, extent, and level of care for home health care services (CMS, 2015). The treating physician should periodically conduct re-assessments of the medical necessity of home health care services at intervals matched to the individual patient condition and needs, for example, 30, 60, 90, or 120 days. Such reassessments may include repeat evaluations in the home.