Palmetto GBA: Tips for LUPA Claims

Palmetto GBA released a fact sheet this week about Low Utilization Payment Adjustment (LUPA) claims for home health care providers. Keep in mind the following tips for low utilization claims for Medicare beneficiaries:

A LUPA occurs when four or fewer visits are provided in a 60-day episode. Instead of payment being based on the Health Insurance Prospective Payment System (HIPPS) code, payment is based on a national standardized per visit payment by discipline instead of an episode payment for a 60-day period. Payment will be wage index adjusted.

Regardless of reason (such as unexpected death, discharge, etc.) if less than four or fewer visits are provided, payment will be based on LUPA per visit rates.

If the provider determines at the beginning of the episode that four or fewer visits will be provided to a patient during the 60-day episode (such as a monthly catheter change), the HHA has the choice to submit a ‘No Requests for Anticipated Payment (RAP) LUPA’ claim. In this case the HHA may submit the final claim for the episode to Medicare without first submitting a RAP.

As with the submission of all final claims under Home Health (HH) Prospective Payment System (PPS), physician’s orders must be signed and dated prior to submitting No-RAP-LUPA claims to Medicare for payment.

When billing No-RAP LUPA claims, all required claim data should be entered as usual for a home health claim, including the ‘Statement Covers Through’ date (FL.6) which should reflect:

  • The 60th day of the episode, or
  • The date the patient transfers to another HHA, or
  • The date the patient is discharged or dies

It may be in the best interest of the HHA to submit RAPs as opposed to doing the No-RAP-LUPA. This establishes the HHA as the primary agency on the Common Working File (CWF) thus ensuring that other HHAs are aware that the patient is currently under the care of an HHA.

An ‘add-on’ payment is made to the first billable visit on LUPA claims when it is the first or only episode in a series of adjacent episodes


  • Whether the HHA decides to submit a RAP and a final claim; or a No-RAP-LUPA, all required home health data is required and should be entered as usual
  • Consolidated billing applies to LUPA episodes as it normally does

Reference: CMS Internet Only Manual (IOM) Publication 100-04, Chapter 10.

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