Despite the fact that payment episodes under the Patient-Driven Groupings Model (PDGM) will last 30 days instead of 60, LUPAs still will occur under the new payment model CMS is creating beginning on or after Jan. 1, 2020.
Unlike with the PPS, where a LUPA involves four or fewer visits during an episode, the threshold for the number of visits needed for an episode to be a LUPA under PDGM will vary.
Thresholds will range from two to six visits, depending on the specific HHRG. PDGM will have 432 HHRGs.
Ten HIPPS codes will have the highest LUPA visit threshold under PDGM.
They are:
|
HIPPS
|
Clinical Group and Functional Level
|
Timing and Admission Source
|
Comorbidity Adjustment
(0 = none, 1 = single comorbidity,
2 = interaction)
|
Visit Threshold (10th percentile or 2 - whichever is higher)
|
|
2EC11
|
MS Rehab - High
|
Early - Institutional
|
0
|
6
|
|
2EC21
|
MS Rehab - High
|
Early - Institutional
|
1
|
6
|
|
2EC31
|
MS Rehab - High
|
Early - Institutional
|
2
|
6
|
|
2EB11
|
MS Rehab - Medium
|
Early - Institutional
|
0
|
6
|
|
2EB21
|
MS Rehab - Medium
|
Early - Institutional
|
1
|
6
|
|
2EB31
|
MS Rehab - Medium
|
Early - Institutional
|
2
|
6
|
|
1BB31
|
Neuro - Medium
|
Early - Community
|
2
|
6
|
|
2BB11
|
Neuro - Medium
|
Early - Institutional
|
0
|
6
|
|
2BB21
|
Neuro - Medium
|
Early - Institutional
|
1
|
6
|
|
2BB31
|
Neuro - Medium
|
Early - Institutional
|
2
|
6
|
Meanwhile, 93 HIPPS codes will have a LUPA threshold of two visits.
Those codes are:
|
HIPPS
|
Clinical Group and Functional Level
|
Timing and Admission Source
|
Comorbidity Adjustment
(0 = none, 1 = single comorbidity,
2 = interaction)
|
Visit Threshold (10th percentile or 2 - whichever is higher)
|
|
3FC11
|
Behavioral Health - High
|
Late - Community
|
0
|
2
|
|
3FC21
|
Behavioral Health - High
|
Late - Community
|
1
|
2
|
|
4FC31
|
Behavioral Health - High
|
Late - Institutional
|
2
|
2
|
|
3FA11
|
Behavioral Health - Low
|
Late - Community
|
0
|
2
|
|
3FA21
|
Behavioral Health - Low
|
Late - Community
|
1
|
2
|
|
3FA31
|
Behavioral Health - Low
|
Late - Community
|
2
|
2
|
|
4FA11
|
Behavioral Health - Low
|
Late - Institutional
|
0
|
2
|
|
4FA21
|
Behavioral Health - Low
|
Late - Institutional
|
1
|
2
|
|
4FA31
|
Behavioral Health - Low
|
Late - Institutional
|
2
|
2
|
|
3FB11
|
Behavioral Health - Medium
|
Late - Community
|
0
|
2
|
|
3FB21
|
Behavioral Health - Medium
|
Late - Community
|
1
|
2
|
|
3FB31
|
Behavioral Health - Medium
|
Late - Community
|
2
|
2
|
|
1DC11
|
Complex - High
|
Early - Community
|
0
|
2
|
|
1DC21
|
Complex - High
|
Early - Community
|
1
|
2
|
|
1DC31
|
Complex - High
|
Early - Community
|
2
|
2
|
|
3DC11
|
Complex - High
|
Late - Community
|
0
|
2
|
|
3DC21
|
Complex - High
|
Late - Community
|
1
|
2
|
|
3DC31
|
Complex - High
|
Late - Community
|
2
|
2
|
|
1DA11
|
Complex - Low
|
Early - Community
|
0
|
2
|
|
1DA21
|
Complex - Low
|
Early - Community
|
1
|
2
|
|
1DA31
|
Complex - Low
|
Early - Community
|
2
|
2
|
|
3DA11
|
Complex - Low
|
Late - Community
|
0
|
2
|
|
3DA21
|
Complex - Low
|
Late - Community
|
1
|
2
|
|
3DA31
|
Complex - Low
|
Late - Community
|
2
|
2
|
|
4DA11
|
Complex - Low
|
Late - Institutional
|
0
|
2
|
|
3DB11
|
Complex - Medium
|
Late - Community
|
0
|
2
|
|
3DB21
|
Complex - Medium
|
Late - Community
|
1
|
2
|
|
3DB31
|
Complex - Medium
|
Late - Community
|
2
|
2
|
|
3GC11
|
MMTA - Surgical Aftercare - High
|
Late - Community
|
0
|
2
|
|
3GC21
|
MMTA - Surgical Aftercare - High
|
Late - Community
|
1
|
2
|
|
3GC31
|
MMTA - Surgical Aftercare - High
|
Late - Community
|
2
|
2
|
|
3GA11
|
MMTA - Surgical Aftercare - Low
|
Late - Community
|
0
|
2
|
|
3GA21
|
MMTA - Surgical Aftercare - Low
|
Late - Community
|
1
|
2
|
|
3GA31
|
MMTA - Surgical Aftercare - Low
|
Late - Community
|
2
|
2
|
|
3GB11
|
MMTA - Surgical Aftercare - Medium
|
Late - Community
|
0
|
2
|
|
3GB21
|
MMTA - Surgical Aftercare - Medium
|
Late - Community
|
1
|
2
|
|
3GB31
|
MMTA - Surgical Aftercare - Medium
|
Late - Community
|
2
|
2
|
|
3HC11
|
MMTA - Cardiac - High
|
Late - Community
|
0
|
2
|
|
3HC21
|
MMTA - Cardiac - High
|
Late - Community
|
1
|
2
|
|
3HA11
|
MMTA - Cardiac - Low
|
Late - Community
|
0
|
2
|
|
3HA21
|
MMTA - Cardiac - Low
|
Late - Community
|
1
|
2
|
|
3HB11
|
MMTA - Cardiac - Medium
|
Late - Community
|
0
|
2
|
|
3HB21
|
MMTA - Cardiac - Medium
|
Late - Community
|
1
|
2
|
|
3IA11
|
MMTA - Endocrine - Low
|
Late - Community
|
0
|
2
|
|
3IA21
|
MMTA - Endocrine - Low
|
Late - Community
|
1
|
2
|
|
3IA31
|
MMTA - Endocrine - Low
|
Late - Community
|
2
|
2
|
|
3IB11
|
MMTA - Endocrine - Medium
|
Late - Community
|
0
|
2
|
|
3JC11
|
MMTA - GI/GU - High
|
Late - Community
|
0
|
2
|
|
3JC21
|
MMTA - GI/GU - High
|
Late - Community
|
1
|
2
|
|
3JC31
|
MMTA - GI/GU - High
|
Late - Community
|
2
|
2
|
|
3JA11
|
MMTA - GI/GU - Low
|
Late - Community
|
0
|
2
|
|
3JA21
|
MMTA - GI/GU - Low
|
Late - Community
|
1
|
2
|
|
3JA31
|
MMTA - GI/GU - Low
|
Late - Community
|
2
|
2
|
|
3JB11
|
MMTA - GI/GU - Medium
|
Late - Community
|
0
|
2
|
|
3JB21
|
MMTA - GI/GU - Medium
|
Late - Community
|
1
|
2
|
|
3JB31
|
MMTA - GI/GU - Medium
|
Late - Community
|
2
|
2
|
|
3KC11
|
MMTA - Infectious - High
|
Late - Community
|
0
|
2
|
|
3KC21
|
MMTA - Infectious - High
|
Late - Community
|
1
|
2
|
|
3KC31
|
MMTA - Infectious - High
|
Late - Community
|
2
|
2
|
|
3KA11
|
MMTA - Infectious - Low
|
Late - Community
|
0
|
2
|
|
3KA21
|
MMTA - Infectious - Low
|
Late - Community
|
1
|
2
|
|
3KA31
|
MMTA - Infectious - Low
|
Late - Community
|
2
|
2
|
|
4KA11
|
MMTA - Infectious - Low
|
Late - Institutional
|
0
|
2
|
|
3KB11
|
MMTA - Infectious - Medium
|
Late - Community
|
0
|
2
|
|
3KB21
|
MMTA - Infectious - Medium
|
Late - Community
|
1
|
2
|
|
3KB31
|
MMTA - Infectious - Medium
|
Late - Community
|
2
|
2
|
|
3AC11
|
MMTA - Other - High
|
Late - Community
|
0
|
2
|
|
3AA11
|
MMTA - Other - Low
|
Late - Community
|
0
|
2
|
|
3AA21
|
MMTA - Other - Low
|
Late - Community
|
1
|
2
|
|
3AB11
|
MMTA - Other - Medium
|
Late - Community
|
0
|
2
|
|
3AB21
|
MMTA - Other - Medium
|
Late - Community
|
1
|
2
|
|
3LC11
|
MMTA - Respiratory - High
|
Late - Community
|
0
|
2
|
|
3LC21
|
MMTA - Respiratory - High
|
Late - Community
|
1
|
2
|
|
3LC31
|
MMTA - Respiratory - High
|
Late - Community
|
2
|
2
|
|
3LA11
|
MMTA - Respiratory - Low
|
Late - Community
|
0
|
2
|
|
3LA21
|
MMTA - Respiratory - Low
|
Late - Community
|
1
|
2
|
|
3LA31
|
MMTA - Respiratory - Low
|
Late - Community
|
2
|
2
|
|
3LB11
|
MMTA - Respiratory - Medium
|
Late - Community
|
0
|
2
|
|
3LB21
|
MMTA - Respiratory - Medium
|
Late - Community
|
1
|
2
|
|
3LB31
|
MMTA - Respiratory - Medium
|
Late - Community
|
2
|
2
|
|
3EC11
|
MS Rehab - High
|
Late - Community
|
0
|
2
|
|
3EC21
|
MS Rehab - High
|
Late - Community
|
1
|
2
|
|
3EA11
|
MS Rehab - Low
|
Late - Community
|
0
|
2
|
|
3EA21
|
MS Rehab - Low
|
Late - Community
|
1
|
2
|
|
3EA31
|
MS Rehab - Low
|
Late - Community
|
2
|
2
|
|
3EB11
|
MS Rehab - Medium
|
Late - Community
|
0
|
2
|
|
3EB21
|
MS Rehab - Medium
|
Late - Community
|
1
|
2
|
|
3BC11
|
Neuro - High
|
Late - Community
|
0
|
2
|
|
3BA11
|
Neuro - Low
|
Late - Community
|
0
|
2
|
|
3BA21
|
Neuro - Low
|
Late - Community
|
1
|
2
|
|
3BA31
|
Neuro - Low
|
Late - Community
|
2
|
2
|
|
3BB11
|
Neuro - Medium
|
Late - Community
|
0
|
2
|
|
3BB21
|
Neuro - Medium
|
Late - Community
|
1
|
2
|