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Instead, you must click below on the button labeled “I DO NOT ACCEPT” and exit from this computer screen. CPT codes, descriptions and other data only are copyright 2012 American Medical Association . To determine the visit threshold, select the appropriate year for your date of service and HIPPS code. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT".
For example, a patient could have a LUPA threshold of 4 in the first 30 days and 2 in the second 30 days. Agencies now know that you have to have more than 4 visits to avoid what we call LUPA land in the first 30 days. Is the patient is not discharged after 30 days, then the agency needs to make more than 2 visits in the second 30 days. Sometimes, a LUPA is inevitable, so it is important to consider the big picture as you think about your 2020 case-mix strategy. Under PDGM, with a 30-day period to assess and treat a patient efficiently, agencies front-load patients with three visits in the first seven days of care.
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Consider integrating additional tools – Homecare Homebase integrates with Medalogix to provide additional utilization guidance based on the unique needs of each patient. Communicate with your patients to avoid potential scheduling conflicts with physician appointments, personal appointments, etc., that could result in a missed visit. Based on the data, LUPAs appeared most likely to occur in the second period under PDGM. Rates also vary highly based on clinical grouping and LUPA threshold. Post-PDGM, there are 432 different LUPA scenarios, with visit thresholds ranging from two to six.
As she walked through this with the client, she turned on the light bulb. They had not paid attention to the magnifying glass threshold ahead of time. One way to analyze your risk for LUPAs within the second 30-day period would be to look at your organization’s 2017 data. First, compare previous data with what it may look like in the new payment model with the use of a LUPA threshold calculator. This will give insight into which 30-day periods and what types of episodes would fall into LUPA home health categories in a PDGM environment.
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Moreover, this type of impact analysis can help agencies understand what their strengths and weaknesses are moving forward. So, it is important to consider the big picture as you think about your 2020 case-mix strategy. It’s imperative to begin thinking about the management of PDGM visit utilization in 30-day periods of care. For example, for LUPA visits of two or less in a second 30-day period, determine if this low visit count is impacting clinical outcomes. Then consider how moving those one or two visits into the first 30-day period would impact the patient’s outcomes.
They simply cannot afford to miss out on that amount of reimbursement, at that rate. Dallas-based Axxess is a home health technology company that provides agencies with cloud-based software solutions. In this article, we will share some helpful tips for updating your home health best practices and managing your LUPAs. We’ll start by reviewing some of the reasons we saw an increase in LUPAs over the past couple of years.
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What was the LUPA threshold and how many visits did the agency make? The first 30 days episode had several visits and the LUPA threshold was easily cleared. The second 30 days had a LUPA threshold of 2 and the agency made 1 visit and discharged the patient.
There are many different factors that can cause a LUPA to occur. An expected LUPA occurs when an agency admits and understands that a particular patient will not require enough visits to exceed the LUPA threshold. An example of this would be a patient who requires a Foley catheter change only once every 30 days.
This shows that we were able to discover $667.68 of additional, otherwise unclaimed revenue in the review of this chart. The LUPA threshold did not change, but often does based on the coding and OASIS suggested change. CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose.
As home health providers know, low-utilization payment adjustments can have a detrimental impact to an agency both clinically and financially. If you remember, one of the biggest changes in pdgm is around lupa. Previously, agencies had to have more than 5 views in an episode to avoid the magnifying glass. Pdgm changed the game in loupes and some agencies have not adjusted well. Instead of being a fixed visit threshold, cms changed the focus from the loupe threshold to a sliding scale of visits based on many other factors such as coding, diagnostic grouping, oasis .
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. Next, is the rationale for the multiple LUPA Threshold levels/volumes.
A while ago, I received a call from a client who was very upset. She was upset that the reimbursement we had calculated for that patient was significantly higher than what the agency had actually received. Did the coding on her system match what was shown on our system? Did the doctor accept the suggested oasis changes we had made?
Previously, OASIS had to be completed, which meant that agencies would know the diagnosis group, HIPPS code, and ultimately the LUPA threshold before the RAP could be submitted. They have a patient, dropped the RAP, but don't know what the LUPA threshold is when developing the Plan of Care . If the agency knows what the LUPA threshold is, they can plan right up front.
In another blog post called pdgm for dummies we explain what pdgm is. One thing agencies are still struggling with is magnifying glass. If a missed visit is on a Tuesday, for instance, even making up for it immediately the next day could lead to a LUPA in the new 30-day periods. Additionally, access to patients in facilities was also a challenge in 2020, which made the scheduling process more difficult. The Centers for Medicare & Medicaid Services has a triple aim for patients to have positive care outcomes, a positive experience of care, and a low per capita cost of care.
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