Low Utilization Payment Adjustment (LUPA) Threshold Lookup

With the home health Patient-Driven Groupings Model (PDGM), the LUPA thresholds vary for a 30-day period of care depending on which of the 432 case-mix groups it is assigned. The LUPA threshold ranges between 2 and 6 visits. A 30-day period with visits less than the LUPA threshold for the payment group is paid the national per visit amount by discipline.

For example, HIPPS code 2CB21 has a threshold of 5 in 2021. Therefore, a LUPA adjustment would be applied when 4 less or visits are provided in the 30-day period.

Reference: The CMS Home Health Patient-Driven Groupings Model homepage

To lookup the visit threshold, select the year for your date of service and enter the HIPPS code below.