LUPAs remain a complicated area under PDGM

Source: Home Health Line

Despite the fact that payment episodes under the Patient-Driven Groupings Model (PDGM) will last 30 days instead of 60, LUPAs still will occur under the new payment model CMS is creating beginning on or after Jan. 1, 2020.

Unlike with the PPS, where a LUPA involves four or fewer visits during an episode, the threshold for the number of visits needed for an episode to be a LUPA under PDGM will vary.

Thresholds will range from two to six visits, depending on the specific HHRG. PDGM will have 432 HHRGs.

View those thresholds at https://go.cms.gov/1RoGVoi.

Ten HIPPS codes will have the highest LUPA visit threshold under PDGM.

They are:

HIPPS
Clinical Group and Functional Level
Timing and Admission Source
Comorbidity Adjustment
(0 = none,  1 = single comorbidity,
2 = interaction)
Visit Threshold (10th percentile or 2 – whichever is higher)
2EC11
MS Rehab – High
Early – Institutional
0
6
2EC21
MS Rehab – High
Early – Institutional
1
6
2EC31
MS Rehab – High
Early – Institutional
2
6
2EB11
MS Rehab – Medium
Early – Institutional
0
6
2EB21
MS Rehab – Medium
Early – Institutional
1
6
2EB31
MS Rehab – Medium
Early – Institutional
2
6
1BB31
Neuro – Medium
Early – Community
2
6
2BB11
Neuro – Medium
Early – Institutional
0
6
2BB21
Neuro – Medium
Early – Institutional
1
6
2BB31
Neuro – Medium
Early – Institutional
2
6
Meanwhile, 93 HIPPS codes will have a LUPA threshold of two visits.
Those codes are:
HIPPS
Clinical Group and Functional Level
Timing and Admission Source
Comorbidity Adjustment
(0 = none,  1 = single comorbidity,
2 = interaction)
Visit Threshold (10th percentile or 2 – whichever is higher)
3FC11
Behavioral Health – High
Late – Community
0
2
3FC21
Behavioral Health – High
Late – Community
1
2
4FC31
Behavioral Health – High
Late – Institutional
2
2
3FA11
Behavioral Health – Low
Late – Community
0
2
3FA21
Behavioral Health – Low
Late – Community
1
2
3FA31
Behavioral Health – Low
Late – Community
2
2
4FA11
Behavioral Health – Low
Late – Institutional
0
2
4FA21
Behavioral Health – Low
Late – Institutional
1
2
4FA31
Behavioral Health – Low
Late – Institutional
2
2
3FB11
Behavioral Health – Medium
Late – Community
0
2
3FB21
Behavioral Health – Medium
Late – Community
1
2
3FB31
Behavioral Health – Medium
Late – Community
2
2
1DC11
Complex – High
Early – Community
0
2
1DC21
Complex – High
Early – Community
1
2
1DC31
Complex – High
Early – Community
2
2
3DC11
Complex – High
Late – Community
0
2
3DC21
Complex – High
Late – Community
1
2
3DC31
Complex – High
Late – Community
2
2
1DA11
Complex – Low
Early – Community
0
2
1DA21
Complex – Low
Early – Community
1
2
1DA31
Complex – Low
Early – Community
2
2
3DA11
Complex – Low
Late – Community
0
2
3DA21
Complex – Low
Late – Community
1
2
3DA31
Complex – Low
Late – Community
2
2
4DA11
Complex – Low
Late – Institutional
0
2
3DB11
Complex – Medium
Late – Community
0
2
3DB21
Complex – Medium
Late – Community
1
2
3DB31
Complex – Medium
Late – Community
2
2
3GC11
MMTA – Surgical Aftercare – High
Late – Community
0
2
3GC21
MMTA – Surgical Aftercare – High
Late – Community
1
2
3GC31
MMTA – Surgical Aftercare – High
Late – Community
2
2
3GA11
MMTA – Surgical Aftercare – Low
Late – Community
0
2
3GA21
MMTA – Surgical Aftercare – Low
Late – Community
1
2
3GA31
MMTA – Surgical Aftercare – Low
Late – Community
2
2
3GB11
MMTA – Surgical Aftercare – Medium
Late – Community
0
2
3GB21
MMTA – Surgical Aftercare – Medium
Late – Community
1
2
3GB31
MMTA – Surgical Aftercare – Medium
Late – Community
2
2
3HC11
MMTA – Cardiac – High
Late – Community
0
2
3HC21
MMTA – Cardiac – High
Late – Community
1
2
3HA11
MMTA – Cardiac – Low
Late – Community
0
2
3HA21
MMTA – Cardiac – Low
Late – Community
1
2
3HB11
MMTA – Cardiac – Medium
Late – Community
0
2
3HB21
MMTA – Cardiac – Medium
Late – Community
1
2
3IA11
MMTA – Endocrine – Low
Late – Community
0
2
3IA21
MMTA – Endocrine – Low
Late – Community
1
2
3IA31
MMTA – Endocrine – Low
Late – Community
2
2
3IB11
MMTA – Endocrine – Medium
Late – Community
0
2
3JC11
MMTA – GI/GU – High
Late – Community
0
2
3JC21
MMTA – GI/GU – High
Late – Community
1
2
3JC31
MMTA – GI/GU – High
Late – Community
2
2
3JA11
MMTA – GI/GU – Low
Late – Community
0
2
3JA21
MMTA – GI/GU – Low
Late – Community
1
2
3JA31
MMTA – GI/GU – Low
Late – Community
2
2
3JB11
MMTA – GI/GU – Medium
Late – Community
0
2
3JB21
MMTA – GI/GU – Medium
Late – Community
1
2
3JB31
MMTA – GI/GU – Medium
Late – Community
2
2
3KC11
MMTA – Infectious – High
Late – Community
0
2
3KC21
MMTA – Infectious – High
Late – Community
1
2
3KC31
MMTA – Infectious – High
Late – Community
2
2
3KA11
MMTA – Infectious – Low
Late – Community
0
2
3KA21
MMTA – Infectious – Low
Late – Community
1
2
3KA31
MMTA – Infectious – Low
Late – Community
2
2
4KA11
MMTA – Infectious – Low
Late – Institutional
0
2
3KB11
MMTA – Infectious – Medium
Late – Community
0
2
3KB21
MMTA – Infectious – Medium
Late – Community
1
2
3KB31
MMTA – Infectious – Medium
Late – Community
2
2
3AC11
MMTA – Other – High
Late – Community
0
2
3AA11
MMTA – Other – Low
Late – Community
0
2
3AA21
MMTA – Other – Low
Late – Community
1
2
3AB11
MMTA – Other – Medium
Late – Community
0
2
3AB21
MMTA – Other – Medium
Late – Community
1
2
3LC11
MMTA – Respiratory – High
Late – Community
0
2
3LC21
MMTA – Respiratory – High
Late – Community
1
2
3LC31
MMTA – Respiratory – High
Late – Community
2
2
3LA11
MMTA – Respiratory – Low
Late – Community
0
2
3LA21
MMTA – Respiratory – Low
Late – Community
1
2
3LA31
MMTA – Respiratory – Low
Late – Community
2
2
3LB11
MMTA – Respiratory – Medium
Late – Community
0
2
3LB21
MMTA – Respiratory – Medium
Late – Community
1
2
3LB31
MMTA – Respiratory – Medium
Late – Community
2
2
3EC11
MS Rehab – High
Late – Community
0
2
3EC21
MS Rehab – High
Late – Community
1
2
3EA11
MS Rehab – Low
Late – Community
0
2
3EA21
MS Rehab – Low
Late – Community
1
2
3EA31
MS Rehab – Low
Late – Community
2
2
3EB11
MS Rehab – Medium
Late – Community
0
2
3EB21
MS Rehab – Medium
Late – Community
1
2
3BC11
Neuro – High
Late – Community
0
2
3BA11
Neuro – Low
Late – Community
0
2
3BA21
Neuro – Low
Late – Community
1
2
3BA31
Neuro – Low
Late – Community
2
2
3BB11
Neuro – Medium
Late – Community
0
2
3BB21
Neuro – Medium
Late – Community
1
2

 

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