Proper billing around LUPAs is on CMS radar

Effective May 28, 2021

Published May 28, 2021

Last Reviewed May 28, 2021

CMS put fresh attention on LUPA thresholds in a note in its weekly MLN newsletter May 27.

A report by the Office of Inspector General in July 2020 suggested CMS could have saved $192 million by targeting claims slightly above the LUPA threshold. These findings were based on 2017 claims that faced a five-visit threshold for LUPAs. Under PDGM, LUPA thresholds now range from 2-6, depending on the case mix.

CMS is encouraging agencies to “bill correctly,” and for them to review the Medicare Home Health Benefit (PDF) and Home Health Prospective Payment System (PDF) booklets to properly bill for services slightly above the LUPA threshold.

For more information, visit the Home Health Prospective Payment System (PPS) webpage and view these additional resources to stay informed on the latest policy and payment updates:

Home Health PPS final rule
Medicare Benefit Policy Manual, Chapter 7 (PDF), Section 10.6
Medicare Claims Processing Manual, Chapter 10 (PDF), Section 10.1.17
Medicare Program Integrity Manual, Chapter 6 (PDF), Section 6.2

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