What is a Lupa in Medicare?

With the implementation of Patient-Driven Groupings Model (PDGM), the Low Utilization Payment Adjustment (LUPA) thresholds changed from four or less visits to a threshold that ranges between two and six visits.

What causes a lupa?

The term itself stands for “Low Utilization Payment Adjustment,” which is a standard per-visit payment for episodes of care with a low number of visits. Currently, LUPA occurs when there are four or fewer visits during a 60-day episode of care.

How many visits make 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.

How do you prevent Lupa?

Train your staff to always attempt to re-schedule visits or have a plan in place where other clinicians are available to make up visits with a patient. Be cautious when tapering visits during the second 30-day payment episode. The practice of tapering visits could inadvertently lead to a potential LUPA.

What is a Lupa episode?

If an HHA provides four visits or less in an episode, they will be paid a standardized per visit payment instead of an episode payment for a 60-day period. Such payment adjustments, and the episodes themselves, are called Low Utilization Payment Adjustments (LUPAs).

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What does the acronym Lupa stand for?

The term itself stands for “Low Utilization Payment Adjustment,” which seems simple enough. However, the real significance of the LUPA comes into play in terms of how we are reimbursed for patient care.

What does Lupa mean in home care?

With the implementation of Patient-Driven Groupings Model (PDGM), the Low Utilization Payment Adjustment (LUPA) thresholds changed from four or less visits to a threshold that ranges between two and six visits.

What is a PDGM Lupa?

LUPA stands for Low Utilization Payment Adjustment. If you remember, one of the biggest changes in PDGM is around LUPA. Previously, agencies had to have more than 5 visits in an episode to avoid LUPA. It was fairly simple. PDGM changed the game on LUPAs and some agencies haven't adjusted well.

What is PDGM?

The Patient-Driven Groupings Model (PDGM) is the biggest change for home health agencies in over two decades. The transition to the new model requires agencies to examine patient needs, comorbidities, and referral sources to determine if their case mix optimizes reimbursement.

What is a home health episode?

Additional requirements to qualify for a Part A episode for home health services are. a face-to-face physician visit with the patient; and. a plan of care established by the certifying physician; and. a need for skilled nursing on an intermittent basis; or. a need for physical therapy; or.

What are the 12 clinical groupings in PDGM?

There are 12 Clinical Groupings: Medication Management Teaching & Assessment (MMTA) – Other, MMTA: Endocrine, MMTA: Cardiac, MMTA: Surgical Aftercare, MMTA: Infectious, MMTA: GI/GU, MMTA: Respiratory, Wounds, Musculoskeletal Rehab, Neuro Rehab, Complex Nursing Interventions & Behavioral Health.

What is a case-mix group in home health?

Case Mix—term used to identify resource use for Medicare providers. For Medicare home health, certain M items indicate clinical severity, functional status and service utilization and determine the case mix score. HHRG—Home Health Resource Group (pronounced 'Herg').

What is a hipps code?

(HIPPS Codes)

Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems.

What is the difference between PDPM and PDGM?

The intent behind these administrative changes, commonly known as the Patient-Driven Payments Model (PDPM) for skilled nursing facilities (SNFs) and the Patient-Driven Groupings Model (PDGM) for home health care, is to improve the quality of patient care, promote the overall health and wellbeing of the Medicare ...

How Much Does Medicare pay for home health care per hour?

Medicare will cover 100% of the costs for medically necessary home health care provided for less than eight hours a day and a total of 28 hours per week. The average cost of home health care as of 2019 was $21 per hour.

How will PDGM affect home health?

PDGM provides the HHA the reimbursement value based on the condition of the patient and the anticipated cost to provide care for that patient. Wound patients cost HHA a lot of time and resources, so wound is reimbursed higher. Cost management is a big factor in the impact HHA will have.

How many clinical groups are under PDGM?

Under the PDGM, each 30-day period is grouped into one of twelve clinical groups based on the patient's principal diagnosis. The reported principal diagnosis provides information to describe the primary reason for which patients are receiving home health services under the Medicare home health benefit.

What is MMTA in home health?

MMTA-Other Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in one of the previous groups. The subgroups represent common clinical conditions that require home health services for medication management, teaching and assessment.

What does the 30 day period under PDGM directly affect in home health care?

ROC OASIS under PDGM A hospital admission and resumption of home care during the first 30-day period of home care would change how the patient's functional status is determined for the second 30-day period.

What are the PDPM codes?

What are the 6 components of PDPM?

In the PDPM, there are five case-mix adjusted components: Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Non-Therapy Ancillary (NTA), and Nursing. Each resident is to be classified into one and only one group for each of the five case-mix adjusted components.

What is revenue code 0023?

Revenue Code 0023 indicates that the billing is for services under the Home Health Prospective Payment System (HHPPS).

How do I calculate CMI?

Case mix index is calculated by adding up the relative Medicare Severity Diagnosis Related Group (MS-DRG) weight for each discharge, and dividing that by the total number of Medicare and Medicaid discharges in a given month and year.

What is a high CMI?

A higher CMI indicates a more complex and resource-intensive case load. Although the MS-DRG weights, provided by the Centers for Medicare & Medicaid Services (CMS), were designed for the Medicare population, they are applied here to all discharges regardless of payer.

What is a good case mix index?

CMI for the top 25 hospitals range from 3.23 to 5.69 with an average CMI of 3.78. There was a slight increase from the average CMI of 3.48 for the top hospitals in 2018. With patients delaying care during the COVID-19 pandemic, hospitals were seeing the most severe patients, potentially increasing CMIs.