Home Health Periods with One or Two Visits Over Low Utilization Payment Adjustments (LUPAs) Thresholds

Published 04/16/2019

If a home health agency (HHA) provides visits under the Home Health Patient-Driven Groupings Model (PDGM) Utilization Payment Adjustment (LUPA) thresholds in a period, they will be paid a standardized per visit payment instead of a payment for a 30-day period. 

Periods with visits just meeting a threshold should be evaluated by providers. This could indicate that the HHA is considering the minimum number of visits to obtain a full period payment instead of a LUPA payment. 

In a recent report, the Office of Inspector General found that Medicare improperly paid some claims for home health services with 5–7 visits in a payment episode (for home health services provided in 2017, prior to the implementation of PDGM). Review the Medicare Home Health Benefit and Home Health Prospective Payment System booklets to properly bill for services slightly above the LUPA thresholds.

The HHA should review documentation to ensure that it clearly substantiates that skilled services were reasonable and necessary to the treatment of the patient’s illness or injury within the context of the patient’s unique medical condition.

If the individualized assessment of the patient does not demonstrate the need for skilled care, such as instances where skilled care could safely and effectively be performed by the patient or unskilled caregivers, such services are not covered under the home health benefit. The HHA should review plans of care to ensure they are individualized and appropriate for the beneficiaries’ condition.


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