food for thought
As a financial consultant to the home health industry, I like to periodically share a free nugget or two of information, and today, I want to say something about the LUPA Thresholds under PDGM.
There have been several significant changes regarding the LUPA Thresholds under PDGM. This post will compare and contrast the LUPA Threshold methodology under Original PPS (2000 thru 2019) and PDGM (eff. Jan 1, 2020) and also identify some points to consider regarding LUPA Thresholds under PDGM.
Remember, PDGM was developed to try to make patient-care more patient-specific; to move away from the cookie-cutter approach of the past! You should always keep this in mind when considering any aspect of PDGM.
The Big Picture Perspective
Original PPS; which had 153 Case-Mix Weights, had only 1 LUPA Threshold; which was 4. So whether you were projecting 5 visits for the episode or 25 visits for the episode, the LUPA Threshold was always 4. This never really made any sense. That was why the LUPA Threshold has been changed under PDGM.
With PDGM, we have 432 unique Case-Mix Weights (i.e., HIPPS Codes), each with its own specific LUPA Threshold. 216 Early Episodes and 216 Late Episodes. The LUPA Thresholds under PDGM range between 2 and 6.
Following is the # of episodes by LUPA Threshold level:
The Meaning of ‘Threshold’
First, let’s consider the term “Threshold” and its meaning/usage in regards to the ‘LUPA Threshold’ under Original PPS (2000 thru 2019) and now under PDGM (eff. Jan 1, 2020):
- Threshold under Original PPS identified the volume of visits that must be exceeded (4) to earn the FULL Episodic payment; at or under the Threshold and your revenues were based on the LUPA Per-Visit Rates
- Threshold under PDGM identifies the volume of visits that must be met (2, 3, 4, 5 or 6) to earn the FULL Episodic payment; under the Threshold and your revenues are based on the LUPA Per-Visit Rates, at or over the Threshold and you earn the FULL Episodic payment.
The Rationale for Multiple Thresholds
Next, is the rationale for the multiple LUPA Threshold levels/volumes. CMS’ rationale is that an episode that has a greater expected resource utilization should have a higher LUPA Threshold level than an episode with a lower expected resource utilization; therefore, the multiple LUPA Thresholds.
Something to consider: It would seem logical that an episode with a higher LUPA Threshold would have more expected visits projected for it than an episode with a lower LUPA Threshold. Meaning:
- a HIPPS Code (an episode) with a LUPA Threshold of 6, ought to generally have more projected visits than a HIPPS Code (an episode) with a LUPA Threshold of 5, and
- a HIPPS Code (an episode) with a LUPA Threshold of 5, ought to generally have more projected visits than a HIPPS Code (an episode) with a LUPA Threshold of 4, and
- etc… down the LUPA Threshold levels
- So, when building the Plan of Care, it would seem logical that the visit utilization projected would be relative to the LUPA Threshold – see the Something to Consider above!
for Early vs Late Episodes
Next, we compare the LUPA Thresholds for Early and Late Episodes. Here, we will focus on the HIPPS Codes:
As previously noted, there are 216 Early and 216 Late Episode Types/HIPPS Codes. For the most part, the LUPA Thresholds of the Late Episodes/HIPPS Codes are less than the LUPA Thresholds for the corresponding Early Episodes/HIPPS Codes; but only for the most part. The LUPA Threshold DOES NOT Change for 23 of the 216 Late Episodes/HIPPS Codes; which means it does drop for 193 of the 216 Late Episodes/HIPPS Codes, and the change for these 193 Late Episodes/HIPPS Codes range from a reduction of 1 to 3 visits compared to what the LUPA Threshold is for the corresponding Early Episodes/HIPPS Codes.
For example, let’s look at the 1st Early HIPPS Code listed by CMS and compare with it’s corresponding Late HIPPS Code:
HIPPS Code Clinical Group/Functional Level Timing/Source
- 1AA11 MMTA-Other-Low Early Community
- 3AA11 MMTA-Other-Low Late Community
1AA11 has a LUPA Threshold of 4
3AA11 has a LUPA Threshold of 2
- So going from an Early to a Late Episode saw the LUPA Threshold drop by 2
See the following as an overview of the changes in the LUPA Thresholds between the 216 Early and the 216 Late Episodes/HIPPS Codes under PDGM:
By paying attention to the LUPA Threshold for each episode you are planning/Plan of Care you are creating, you should be able to better manage not only your volume of LUPAs, but also better manage your resource/visit utilization as well.
And, the better you are able to manage your resource/visit utilization on a case-by-case basis, the better your financial outcomes should be on an episodic basis as well as in the aggregate. Having an accurate, user-friendly tool/app to help you strengthen the correlation between the OASIS and the Plan of Care greatly enhances your ability to provide high-quality care whilst still generating a strong bottom-line. The Resource Planner is the most versatile, user-friendly app to help with this process. It was the first in the industry to do this, and is still the best and most accurate,