What diagnoses are eligible for home health care?

Home Health Eligibility: Diagnoses and Qualifying Criteria

Home health care is available for patients with acute illness, long-term health conditions, permanent disability, or terminal illness who require skilled nursing, therapy services, or medical equipment in their residence. 1

Broad Diagnostic Categories Eligible for Home Health

Home health services are not restricted to specific diagnoses but rather to patients who meet functional and medical criteria across multiple conditions 1:

Respiratory Disorders (Most Common)

• COPD is the most frequent diagnosis for home health referrals among respiratory conditions, representing the fourth most common reason for Medicare hospital discharge to home care 1
• Pneumonia (fifth most common reason for discharge to home care) 1
• Cystic fibrosis requiring home IV antibiotics, oxygen therapy, or tube feedings 1
• Obstructive sleep apnea requiring CPAP therapy 1
• Patients requiring mechanical ventilation at home 1
• Respiratory failure requiring tracheostomy care and secretion management 1

Cardiovascular Conditions

• Heart failure (common home health population with substantial rehospitalization rates) 2
• Chronic heart failure, particularly when dually diagnosed with COPD 1
• Cardiac dysfunction requiring medication management and monitoring 3, 4

Neurological and Functional Disorders

• Paralytic syndromes (1.8% of home health recipients) 1
• Stroke requiring rehabilitation and ADL assistance 5
• Intellectual disability with multiple psychiatric comorbidities requiring medication management 6

Oncologic Conditions

• Malignant neoplasms of trachea, bronchus, and lung (0.9% of home health recipients) 1
• Terminal cancer requiring palliative care 1, 7

Psychiatric Conditions

• Multiple psychiatric diagnoses (schizophrenia, OCD, bipolar disorder) requiring skilled nursing oversight for medication management 6

Qualifying Criteria Beyond Diagnosis

The diagnosis alone does not determine eligibility—patients must meet specific functional and medical criteria 8:

Functional Limitations (Primary Qualifier)

• Impairment in ADLs (bathing, dressing, toileting, transferring, continence, feeding) requiring assistance 8
• Impairment in IADLs (meal preparation, housekeeping, medication management) 6, 8
• Documented level of assistance needed: standby assist, minimal/moderate/maximal assistance, or total dependence 8

Medical Complexity Indicators

• Multiple comorbidities contributing to functional decline 8
• New disease diagnosis requiring skilled assessment and education 8
• More than one emergency room visit or hospital admission in the past year 8
• Inability to attend outpatient services due to medical condition 8

Homebound Status (Medicare Requirement)

• Patient cannot leave home without considerable and taxing effort 8
• Medical contraindication to leaving home 8
• Cognitive impairment requiring familiar environment for safety 8

Need for Skilled Services

• Skilled nursing for wound care, IV therapy, medication management, patient education, or disease monitoring 6, 8
• Physical therapy for mobility impairment, deconditioning, or fall risk 8
• Occupational therapy for ADL training and home safety assessment 8
• Home health aide services (only when ordered with skilled services) 6

Special Populations and Service Models

Hospice Services (Terminal Illness)

• Predicted life expectancy of 6 months or less 1, 7
• Patient has elected palliative rather than curative care 1, 7
• Goals include physical and psychological comfort and enabling death at home 1, 7

Pediatric Patients

• Children with cystic fibrosis requiring home therapies 1
• Promotion of optimal growth and development in children with lung disease 1
• Home apnea monitoring 1

Geriatric Patients

• Older adults living alone with functional limitations 8
• Patients with ADL/IADL limitations and lack of spouse caregiver 1
• Educational attainment less than 12 years (risk factor for home care need) 1

Common Pitfalls to Avoid

Do not assume diagnosis alone qualifies a patient—Medicare requires documentation of homebound status, functional limitations, and need for skilled services regardless of diagnosis 8. A patient with severe COPD who is ambulatory and managing independently does not qualify, while a patient with mild COPD who has severe functional decline from deconditioning may qualify 8.

Personal care services alone are not covered—home health aide services for meal preparation and housekeeping can only be ordered when skilled nursing or therapy services are also provided 6. This is a frequent documentation error that leads to claim denials.

Avoid vague functional descriptions—use standardized terminology with precise levels of assistance for each ADL rather than general statements like "patient is weak" 8. Specific documentation such as "requires moderate assistance with bathing due to dyspnea and inability to stand for prolonged periods" is necessary for approval.