Pre-Claim Review (PCR) and Low Utilization Payment Adjustments (LUPAs)

With the transition to the Home Health Patient-Driven Groupings Model (PDGM), CMS will phase-in the inclusion of LUPAs within the Review Choice Demonstration. The below information reflects the implementation timeframe. The dates provided in this article are episode/period start date driven.

Prior to January 1, 2020
Number of Visits Per Claim
1
2
3
4
5
6+
Included in PCR
No
No
No
No
Yes
Yes

For episode start dates prior to January 1, 2020, four (4) or fewer visits were considered LUPAs and were omitted from the PCR option.

After January 1, 2020
Number of Visits Per Claim
1
2
3
4
5
6+
Included in PCR
No
No
No
No
Yes
Yes

For period start dates on or after January 1, 2020, and up to and including March 31, 2020, LUPAs with four (4) or fewer visits do not require a PCR request submission. However, each claim will be reimbursed based on the PDGM LUPA thresholds. LUPAs with five (5) or more visits will need a PCR request or an Additional Documentation Request (ADR) will be generated and there will be a 25 percent reduction to the full claim amount.

After April 1, 2020
Number of Visits Per Claim
1
2
3
4
5
6+
Included in PCR
Yes
Yes
Yes
Yes
Yes
Yes

For period start dates on or after April 1, 2020, all LUPAs are required to have a PCR request or an ADR will be generated and there will be a 25 percent reduction to the full claim amount.

The full list of LUPA thresholds can be found on the
Home Health Agency (HHA) Center webpage. The list of LUPA thresholds displays the number of visits needed for a 30-day period of care payment. For example, HIPPS code 3FC11 has a two (2) visit threshold. Therefore, one (1) visit in the period of care is a LUPA payment and two (2) or more visits in the period of care would receive full payment for a 30-day period of care.

For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s HHRG, they will be paid a standardized per visit payment instead of a payment for a 30-day period of care.

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