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Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator

Under the Home Health Patient-Driven Groupings Model (PDGM), each case-mix group is assigned a LUPA visit threshold to determine if a period of care receives a low utilization payment adjustment (LUPA). If a home health agency provides fewer visits than the threshold specified for the period’s HHRG, it receives a standardized per-visit payment (LUPA) rather than a case-mix adjusted 30-day payment rate.

Example: The LUPA visit threshold for 1FA21 is 3 visits. A 30-day period with less than 3 visits is paid per visit (LUPA). A 30-day period with 3 or more visits is paid the case-mix adjusted 30-day payment rate.

Reference: Pub. 100-04, Ch. 10, Section 10.1.17External PDF.

To determine the visit threshold, select the appropriate year for your date of service and HIPPS code.

Year of Service:


Disclaimer: CGS' online tools and calculators are informational and educational tools only, designed to assist suppliers and providers in submitting claims correctly. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided. Although we've made every reasonable effort to provide effective resources, CGS is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information that these tools provide. CGS is not responsible for any human or mechanical errors or omissions.


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