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  • Low Utilization Payment Adjustment (LUPA) Add-on Amounts for Home Health (HH) Occupational Therapy Visits and Corrections to Payment Grouping Processes

Low Utilization Payment Adjustment (LUPA) Add-on Amounts for Home Health (HH) Occupational Therapy Visits and Corrections to Payment Grouping Processes

6 Aug 2021 1:04 PM | Zachary Edgar (Administrator)

Issue Date: 8/6/2021

Effective Date: 1/32/2022

This change request makes changes to Original Medicare systems to allow for LUPA add-on payments to apply if an occupational therapy visit is the first visit in a period of care.

Background

Under the Consolidated Appropriations Act, 2021 (CAA 2021), the regulations at §§ 484.55(a)(2) and 484.55(b)(3) were revised to allow Occupational Therapists (OTs) to conduct initial and comprehensive assessments for all Medicare beneficiaries under the home health benefit when the plan of care does not initially include skilled nursing care. That is, occupational therapists may conduct the initial assessment and complete the comprehensive assessment, but only when occupational therapy is on the home health plan of care with either physical therapy and/or speech therapy and skilled nursing services are not initially on the plan of care. Because of this change, CMS must establish a LUPA add-on factor in calculating the LUPA add-on payment amount for the first skilled occupational therapy visit in LUPA periods that occur as the only period of care or the initial 30-day period of care in a sequence of adjacent 30- day periods of care.

This change request also contains requirements to ensure consistent and accurate processing of HH claims under the Patient-Driven Groupings Model.

All HH claims are matched to their associated Outcomes and Assessment Information System (OASIS) assessment during processing and use certain OASIS items to determine the Health Insurance Prospective Payment System (HIPPS) code used for payment. Medicare Administrative Contractors (MACs) have reported intermittent failures in the claims-OASIS matching process. When MACs observe unusually high volumes of HH claims in suspense locations awaiting a match, they may recycle the claims to the assessment system a second time. Per instructions in publication 100-04, chapter 10, section 10.1.10.1, MACs may take this action at their discretion or when notified by CMS. Requirements four and five ensure the recycled claims process correctly in all cases.

Similarly, on all HH claims, the HH Grouper program must calculate the HIPPS code used for payment. MACs have reported intermittent cases where HH claims bypass the HH Grouper and have paid using the provider-submitted HIPPS code. Requirement six creates a safeguard to prevent this.

Policy

Currently, there are no sufficient data regarding the average excess of minutes for the first visit in LUPA periods where the initial and comprehensive assessments are conducted by OTs. Therefore, in the Calendar Year (CY) 2020 HH Prospective Payment System (PPS) final rule, CMS finalized to utilize the Physical Therapy (PT) LUPA add-on factor of 1.6700 as a proxy for the OT LUPA add-on factor for CY 2022 until we have CY 2022 data to establish the OT add-on factor for the LUPA add-on payment amounts in future years. The similarity in the per-visit payment rates for both PT and OT make the PT LUPA add-on factor the most appropriate proxy until CMS has sufficient data to establish the OT LUPA add-on factor.

Reference

Centers for Medicare & Medicaid Services

Transmittal 10919


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