CMS Pub. 100-04, ch. 10, § 10.1.17

(LUPAs)

(Rev. 10919, Issued:08-06-21, Effective:01-01-22, Implementation: 01-03-22)

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. Such payment adjustments are called

Low Utilization Payment Adjustments (LUPAs).

On LUPA claims, nonroutine supplies will not be reimbursed in addition to the visit

payments, since total annual supply payments are factored into all payment rates. If the

claim for the LUPA is later adjusted such that the number of visits is equal to or greater

than the threshold for the HHRG, payments will be adjusted to an HHRG basis, rather

than a visit basis.

If the LUPA period is the first in a sequence of adjacent periods or is the only period of

care the beneficiary received, Medicare will make an additional add-on payment.

Medicare will add to these claims an amount calculated from a factor established in

regulation. This additional payment will be reflected in the payment for the earliest dated

revenue code line representing a home health visit for skilled nursing, physical therapy,

occupational therapy (after January 1, 2022), or speech-language pathology.

One criterion that Medicare uses to determine whether a LUPA add-on payment applies

is that the claim Admission Date matches the claim “From” Date. HHAs should take

care to ensure that they submit accurate admission dates, especially if claims are

submitted out of sequence. Inaccurate admission dates may result in Medicare systems

returning LUPA claims where an add-on payment applies, but the add-on was paid

inappropriately on a later dated period in the same sequence.

Additionally, Medicare systems may return to the provider LUPA claims if the claim

meets the criteria for a LUPA add-on payment but it contains no qualifying skilled

service. In these cases, the HHA may add the skilled visit to the claim if it was omitted

in error and re-submit the claim. Otherwise, the HHA may only re-submit the claim

using condition code 21, indicating a billing for a denial notice.

10.1.18 – RESERVED