Module 1, Topic 1
In Progress

Day 2: Final Claims

Petria September 3, 2020

Final Claims

Episode Exceptions:

  • Outlier Payments
  • Low Utilization Payment Adjustment (LUPA)
  • Partial Payment Adjustment (PPA)


Limitation on Home Health Perspective Payment System (HH PPS) Outlier Payments

  • Effective January 1, 2010 (for CY 2010), the outlier payments made to each HHA will be subject to an annual limitation. Medicare systems will ensure that outlier payments comprise no more than 10 percent of the HHA’s total HH PPS payments for the year.
  • Medicare will not pay partial outlier payments. Outlier payments will be made for a particular claim only if the entire outlier payment on a claim does not result in the limitation being met for a HHA.
  • When a calculated outlier is not paid due to the limitation, the HHA will be notified via claim adjustment reason code 45 (“Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.”) on the accompanying remittance advice.
  • Under PDGM, CMS will maintain the current methodology for outlier payments and will calculate payment based on 30 day periods of care.


Low Utilization Payment Adjustment (LUPA)

  • LUPA Threshold depends on the Clinical Grouping the patient is in
    • 2-6 visits within the 30 day period
  • Reason is not relevant
  • Qualifying and non-qualifying visits count
  • Paid at visit rate versus the full episode or prorated episode payment rate
  • To RAP or Not to Rap



In the final rule, CMS stated, “there are substantially more home health periods of care with 4 or fewer visits in a 30 day period than in a 60 day episode; therefore, we believe that the LUPA thresholds for 30 day periods of care should be correspondingly adjusted to target approximately the same percentage of LUPA episode as under the current HH PPS case mix system, which is approximately 7 to 8 percent of all episodes.”

  • The LUPA threshold for each 30 day period varies depending on the PDGM payment group to which it is assigned.
  • Under PDGM, if the LUPA threshold is met, the 30 day period will be paid the full 30 day period payment.
  • If the 30 day threshold is not met, the payment will be made using the CY 2020 per visit payment amounts.
  • There will continue to be a LUPA add on factor payment in LUPA periods that occur as the only period of care or the initial 30 day period of care in a sequence of adjacent 30 day periods of care. The proportional payment will be based on a 30 days instead of a 60 days formula


LUPA Thresholds

  • Variable thresholds based on HHRG
  • Different level for each of the 432 HHRGs
  • Utilize 10th percentile value of visits for each threshold
  • LUPA reimbursement is per visit (as prior PPS)
  • PDGM LUPA ‘speak’ is that you will be paid by the visit for visits less than the threshold (Ex: A ‘4 visit LUPA’ means reimbursement by the visit if below 4 visits)


In PDGM, there are 432 unique Case-Mix Weights or HIPPS codes and each has its own specific LUPA Threshold.

  • 216 Early Episodes & 216 Late Episodes
  • The LUPA Thresholds under PDGM ranges between 2 and 6.

Listed below are the # of episodes by LUPA Threshold level:


Now “Threshold” under PDGM means the # of visits that must be done (2, 3, 4, 5 or 6) to earn the FULL Period payment

Again, if the # of visits fall under the “Threshold” then your reimbursement is based on the LUPA Per-Visit Rates, at or over the Threshold and you earn the FULL Period payment.



HIPPS Code LUPA Example

1AA11 MMTA-Other-Low Early Community
3AA11 MMTA-Other-Low Late Community

  • 1AA11 has a LUPA Threshold of 4
  • 3AA11 has a LUPA Threshold of 2
  • LUPA Thresholds changes between the 216 Early & the 216 Late Episodes/HIPPS Codes under PDGM:


Where to Start With Managing LUPAs

Develop LUPA results for ongoing team management(finance/clinical)

  • Information evaluation includes: –Timing of the LUPA in payment period (Days 1-30, early/late)
    • Days from SOC evaluations completed
    • Visit frequency of disciplines
    • Diagnosis
  • Reasons for LUPA
    • Homebound status
    • Physician request discharge
    • Patient refusal
    • Were patient outcomes achieved?
  • Education Opportunities:
    • Clinical managers/clinical staff on LUPA impact both financially and on patient outcomes
    • Physicians on PDGM changes
  • High LUPA (greater 10%) develop Performance Improvement Project with clinical department based on findings from evaluation of LUPAs

Remember LUPAs are a PEPPER Target Area – Are you an Outlier?



Estimated Periods by Clinical Grouping Provided by CMS

  • MMTA, 56.7% (Medical Management, Teaching and Assessment)
  • MS Rehab, 16.6%
  • Wound, 10.5% (now top paying clinical grouping)(still can be costly)
  • Complex Nursing Interventions, 3.9%
  • Neuro/Stroke Rehab, 8.9%
  • Behavioral Health, 3.3%


Partial Payment Adjustment(PPA)

  • Occurs anytime a beneficiary is readmitted to HOME HEALTH CARE (whether with a different agency or the same agency) during an existing 30 day period
  • Beneficiary elects transfer to another HHA
  • Discharge and readmit to the same HHA
  • The process of Partial Payment Adjustments for 30 day periods of care will remain the same as the process for 60 day episodes. The proportional payment will be based on 30 days instead of 60 days formula



Adjustments for beneficiaries who change HHAs or are discharged and readmitted within a 60-day episode

The home health PPS will include a partial payment adjustment (PPA). A new episode clock will be triggered when a beneficiary elects to transfer to another HHA or when a beneficiary is discharged and readmitted to the same HHA during the 60-day episode.




  • Transfers from one agency to another can cause problems so know how to protect your agency
  • Gaining agency must check HIQH/ELGH to verify patient status (Page 3) and have copy on file
  • Gaining agency must contact the initial HHA to inform them of the transfer and document the contact
  • Gaining agency must notify the beneficiary that the first HHA will no longer be able to provide services (have Elected Beneficiary Transfer on file)


Elected Beneficiary Transfer Example

ABC Home Health
Elected Beneficiary Transfer

I,________________, would like to receive home health services from ABC Home Health instead of XYZ Home Health. I have notified XYZ Home Health on _________________ and spoke with ________________ and informed them that I will no longer need their services effective ___________________.
Patient Signature and Date




When disputes arise:

  • 1st agency (agency who lost the patient) will utilize the MAC’s website to find out who the other agency is
  • MAC usually request that the two agencies try and resolve the matter themselves
  • If a resolution does not occur, the 1st agency must put in writing a correspondence letter explaining to the MAC Service Center the situation (see example letter)
  • The MAC will in turn research the situation by utilizing the DDE/FISS system and contacting the 2nd agency for proof that the transfer policy was followed
  • Transfer policy followed – PPA stands
  • Transfer policy not followed – 2nd agency’s claim is canceled (either voluntarily by agency or by force through the MAC)





Gaining agency must document transfer admission no later than 2 business days after the date of admission

Gaining agency must supply requested documentation to the MAC within 48 hours


PDGM Payment Adjustments

  • LUPAs & add-on
    • Paid same methodology as PPS but LUPA threshold
      applied to each separate Group case-mix specific 30-day payment period (CMS expects to see a lot more LUPAs in the 2nd 30 day period)
  • PPAs
    • Paid same methodology as PPS but prorated over 30-day payment period; are now called Partial Payment Adjustments, instead of PEPs
  • Outliers
    • Paid same methodology as PPS but outlier cost & threshold measured over 30-day period

CMS doesn’t trust us to code our claims correctly anymore