Manual Correction Required for Certain LUPA Add-Ons

CMS Says Agency Plans to Fix Problem

The Centers for Medicare & Medicaid Services recently responded to a request from the National Association for Home Care & Hospice to investigate a report that LUPA (Low Utilization Payment Adjustment) add-on payments are not made correctly in certain cases. Specifically, episodes are not being paid correctly when an agency projects 20 or more therapy visits in an early episode, but the patient is discharged from care after only four or fewer home health visits. In these cases the first digit assigned to the Home Health Resource Group (HHRG) is “5” and is defined as 20 or more therapy visits in an early or late episode. The current PPS Pricer does not recognize “5” as eligible for LUPA add-on payments and does not autocorrect when an episode qualifies as a LUPA.

CMS promptly responded, thanking NAHC for bringing this to their attention. CMS plans to correct the PPS Pricer to ensure that LUPA claims with a HHRG projected at 20 or more therapy visits will be automatically regrouped by the system by changing the first digit of the HHRG from “5” to “1”. However, according to CMS “the timing is unfortunate since the January HH Pricer update has already been completed and is in the process of being installed by the FISS maintainer.” As a result, the LUPA add-on correction will be delayed until the next HH Pricer release, with installation as late as January 2014 as the worst case scenario. Until that time, in order to receive the LUPA add-on, home health agencies must cancel and resubmit any early episode claims that projected 20 or more therapy visits that resulted in a LUPA. Resubmitted claims should be assigned a HHRG for low therapy, early episode with a “1” as the first digit in the HHRG.

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