How Can LUPA Be Avoided in Home Health?

by Keith Grunig

Home Health Nurse with Headache

What does LUPA stand for in Home Health?

With PDGM and home health in 2021, agencies have a lot to juggle.  Agencies are dealing with a pandemic.  PDGM started in 2020, but then a pandemic really took the focus of agencies, and understandably so.  In another blog post called PDGM for Dummies we explain what PDGM is.  One thing that agencies are still struggling with is LUPA.  LUPA stands for Low Utilization Payment Adjustment.  

If you remember, one of the biggest changes in PDGM is around LUPA.  Previously, agencies had to have more than 5 visits in an episode to avoid LUPA.  It was fairly simple.  PDGM changed the game on LUPAs and some agencies haven't adjusted well.  Rather than being a fixed visit threshold, CMS changed the LUPA threshold approach to a sliding scale of visits based on a lot of other factors like coding, diagnosis grouping, OASIS (M1800 questions).  (Click on this link to see what OASIS questions PDGM focuses on PDGM OASIS questions)  The new LUPA threshold is a sliding scale between 2 and 6 visits for each 30 day episode.  This is important- this is for each 30 day episode.  

What is LUPA threshold in PDGM and how to avoid it?

Perhaps the easiest way to avoid a LUPA is to know what the thresholds are right up front. One of the biggest factors on avoiding LUPA is to have accurate diagnosis coding and OASIS review.  That is essential to make sure the LUPA is correct so you're going off the best information! One of the unintended consequences of the No Pay RAP in 2021, is that OASIS does not have to be completed to submit the RAP.  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.  Now agencies could have a blind spot.  They have a patient, dropped the RAP, but don't know what the LUPA threshold is when developing the Plan of Care (POC or 485).  If the agency knows what the LUPA threshold is, they can plan right up front.  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.  

A while ago, I had a customer call that was very upset.  She was upset that the reimbursement that we had calculated for that patient were significantly higher than what the agency had actually received.  She wanted to know why.  We started to trouble shoot.  Did the coding match in their system what showed in our system?  It did.  Did the clinician accept the suggested OASIS changes that we had made?  Yes.  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.  As a walked through this with the client, the light bulb went on.  They hadn't paid attention to the LUPA threshold ahead of time.  That cost the agency almost $2,000 for one simple thing.  

LUPA situations

CMS had projected that about 10% of all claims were LUPAs.  With the pandemic, the LUPA rate increased to about 25%.  There are various reasons for this, some included the patients did not want clinicians coming into their homes for fear of getting sick.  Some did not have staff available to visit.  Some would not visit sick patients.  

Some agencies have situations where they think a LUPA cannot be avoided.  Some can't.  A common situation where a LUPA can be avoided would be a patient with a foley catheter.  Many agencies go in once per month to change the catheter and accept a LUPA.  Can other things be ordered, like sending in a home health aide to check on the patient?  Many times, that can help avoid the LUPA.  Foley Catheter patients also have a high reimbursement rate, so it is in the best interest of the patient and agency to make a plan that can help avoid the LUPA in the first place, and being proactive about that plan.  

LUPA- knowledge is power

At Home Care Answers, we believe that data drives decisions.  But great data drives great decisions.  We have created a PDGM Calculator so when we do OASIS review for agencies, we can provide key information like the reimbursement calculation, HIPPS code, Case Mix, and also LUPA Threshold.  We send you the information to review right up front so that you can have the best data to make the best decision.  This is what it looks like on our report.  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.  

Financial Summary

PDGM First 30 Days

Second 30 Days

Prior-Audit Amount




Post-Audit Amount




Additional Amount




LUPA Thresholds

PDGM First 30 Days

Second 30 Days

Pre-Audit Threshold




Post-Audit Threshold




Case Mix Summary

PDGM First 30 Days

Second 30 Days

Pre-Audit Case Mix




Post-Audit Case Mix




Case Mix Difference





PDGM First 30 Days

Second 30 Days











Here is a great link about LUPA management from HomeCare Magazine.


By proactively planning visits and using good data, you can avoid spending time in LUPA land!  



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