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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. Sometimes, a LUPA is inevitable, so it is important to consider the big picture as you think about your 2020 case-mix strategy. Under PDGM, with a 30-day period to assess and treat a patient efficiently, agencies front-load patients with three visits in the first seven days of care.
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Consider integrating additional tools – Homecare Homebase integrates with Medalogix to provide additional utilization guidance based on the unique needs of each patient. Communicate with your patients to avoid potential scheduling conflicts with physician appointments, personal appointments, etc., that could result in a missed visit. Based on the data, LUPAs appeared most likely to occur in the second period under PDGM. Rates also vary highly based on clinical grouping and LUPA threshold. Post-PDGM, there are 432 different LUPA scenarios, with visit thresholds ranging from two to six.
Therefore, all team members need to be aware of what this number is. Axxess is a partner helping providers on the journey to PDGM success. We have created a wide variety of resources to help providers understand the new regulations, including on-demand webinars, web articles, and quick reference guides. We are also incorporating features into our software to help our clients understand the impact of PDGM on the clinical, operational, and financial process and provide suggestions for improvement. In the first three months of the year when home health agencies were adjusting to the Patient-Driven Groupings Model , the national low-utilization payment adjustment rate hit 9.5%.
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AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. As you have seen there is a detrimental impact of on the agency hence it important to understand factors that are currently causing LUPAs with your PDGM committee. This PDGM committee should randomly review a percentage of LUPA episodes with varying diagnoses each month for the next three to four months.
They simply cannot afford to miss out on that amount of reimbursement, at that rate. Dallas-based Axxess is a home health technology company that provides agencies with cloud-based software solutions. In this article, we will share some helpful tips for updating your home health best practices and managing your LUPAs. We’ll start by reviewing some of the reasons we saw an increase in LUPAs over the past couple of years.
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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.
Under PDGM each of the case mix groups has a threshold to determine if the period of care would receive a LUPA. Payments for 30-day periods with a low number of visits are not case-mix adjusted, but instead paid on a per-visit basis using the national per-visit rates. You can’t miss out on the possibility where the first 30-day care plan with the additional visits might produce better outcomes and the second 30-day period may not be needed and a LUPA can be avoided.
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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. CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose.
Figure 1 shares a summary of the visit thresholds and related number of HHRGs and top clinical groups, under the current PDGM guidance as provided by Medicare. When I looked a little bit deeper at the claim, I spotted the reason for the discrepancy and explained that the patient’s episode was a LUPA. First, understand factors that are causing LUPAs in your patient population well in advance of 2020. Your PDGM committee should begin now by randomly reviewing a percentage of LUPA episodes with varying diagnoses. Continue this review process monthly for the next three to four months.
This preparation includes conducting an intense review of your current LUPAs and understanding the impact that 30-day periods of care will have once PDGM is implemented in 2020. It will be no surprise to you by now that Low-Utilization Payment Adjustments can have a detrimental impact on home health agencies both clinically and financially. Clinically speaking, it is difficult to obtain the best patient outcomes with very few visits.
Centers for Medicare & Medicaid Services crafted PDGM with built-in assumptions that home health providers would do everything possible to avoid LUPAs. That view was partially why PDGM came with a 4.36% behavioral adjustment. Catering to more than 40 specialties, Medical Billers and Coders is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place. In certain instances, a provider won’t know what a patient’s HIPPS code is until 10 days in, which is now a third of the way into the period, Seabrook said.
Perhaps the easiest way to avoid a magnifying glass is to know what the thresholds are from the start. One of the most important factors in avoiding the magnifying glass is having an accurate diagnostic coding and review of the oasis. That’s essential to make sure the loupe is correct so you get the best information! One of the unintended consequences of rapping without payment in 2021 is that you don’t need to complete oasis to send the rap. Previously, oasis had to be completed, which meant agencies would know the diagnostic pool, hipps code, and ultimately the lupa threshold before they could send the rap. They have a patient, they dropped the rap, but they don’t know what the lupa threshold is when developing the plan of care .
From the findings of your internal LUPA review process, first, analyze your results and identify whether the LUPA could have been avoided. Second, investigate trends in avoidable versus unavoidable LUPA cases. Finally, start developing processes to correct avoidable LUPAs and begin educating your staff on these best practices for care. As we march forward in patient reform, agencies need to remember that almost all LUPA’s are preventable and avoidable under PDGM. However, as the management of LUPA episodes has always been a challenge under PPS, it just gets more complex under PDGM. The key is for agencies to continue to deliver efficient OASIS coding practices and strategically manage all of their episodes efficiently.
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