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Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator

Under the home health Patient-Driven Groupings Model (PDGM), each of the 432 case-mix groups has a threshold to determine if the period of care would receive a LUPA.  Currently, the LUPA threshold ranges between 2 and 6 visits.  A RAP is not required for LUPA periods of care; however, it is more challenging to predict when a period of care will result in a LUPA since it’s based on variable thresholds. 

For periods of care beginning on or after January 1, 2020, if a home health agency provides fewer than the threshold of visits specified for the period’s HHRG, they will be paid a standardized per visit payment, or a Low Utilization Payment Adjustment (LUPA), instead of a payment for a 30-day period of care. 

For example: The threshold for 1FA21 is 4 visits. A LUPA adjustment would be applied when fewer than 4 visits (3 or less) are provided in the 30-day period. Refer to the Centers for Medicare & Medicaid Services (CMS) Pub. 100-04, Ch. 10, Section 10.1.17External PDF.

Reference: The CMS Home Health Patient-Driven Groupings ModelExternal Website Web Page.

To determine the visit threshold, enter the HIPPS code.


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