When does a home health period become a LUPA in 2027?

Under PDGM, each 30-day period lands in one of 432 payment groups, and each group has its own LUPA threshold, a minimum number of visits. CMS sets it at the 10th percentile of visits for periods in that group, and never below two. A period with fewer visits than its threshold is a LUPA, and Medicare pays it visit by visit instead of paying the full period.

Meeting the threshold exactly is enough. In CMS's example, with a threshold of four, four visits get the full payment and three are paid per visit.

The rule counts "total visits" without naming a discipline. In our read, that means everyone's visits added together, aide and social work visits included; have your biller confirm that against your contractor's guidance.

MedPAC reports that about 7% of traditional Medicare 30-day periods were LUPAs in 2024. The average period had 8.3 in-person visits.

CMS reset all 432 thresholds using 2025 claims, and the rule's payment provisions take effect January 1, 2027. Before then, confirm your billing system carries the new thresholds.

By our count of CMS's 2026 and 2027 files, 38 groups move by exactly one visit: 23 drop and 15 rise. The rule itself names a one-visit decrease for ten groups and an increase for one; in our reading, those numbers compare July's proposed thresholds with the final ones, while our 38 compares 2026 with 2027.

Early periods (the first 30 days) and patients admitted from an institution carry the higher thresholds. In 2027, a late period for a patient admitted from the community needs two or three visits, and an early period for a patient admitted from an institution needs three to five. The 38 moves by admission source and timing, 2026 to 2027, with 108 groups in each row:

To find your own groups, read the five-character HIPPS code on your paid claims and look each one up in table 11 of the final rule (91 FR 72052 to 72061).

Each visit is paid at the national per-visit rate for its discipline, adjusted by the wage index, which reflects the relative level of wages where the patient lives. The 2027 rates rise 2.1%: skilled nursing $180.66, physical therapy $197.46, occupational therapy $198.81, speech-language pathology $214.64, medical social services $289.57 and home health aide $81.79. The 3% temporary cut in the 30-day base rate doesn't apply to them.

If the LUPA is the patient's only period, or the first in a run of adjacent periods, the first skilled nursing, PT, OT or speech visit is multiplied by an add-on factor: 1.7200 for nursing, 1.6225 for PT, 1.7238 for OT and 1.6696 for speech, unchanged for 2027.

Take group 1GB21, assuming the period is the patient's only one or the first in a run, so the add-on applies; the dollar figures are by our arithmetic from the national rates, before wage adjustment and outliers.

1. The group. 1GB21 (surgical aftercare, medium function, early community, one comorbidity) drops from three visits to two in 2027.
2. The period. Two skilled nursing visits.
3. At the 2027 threshold of two. The period pays in full: the $2,092.69 base rate times the group's 1.0559 weight, $2,209.67.
4. At the 2026 threshold of three. The same two visits would be a LUPA: $310.74 for the first visit with the add-on and $180.66 for the second, $491.40 at 2027 rates.

Medicare checks that the claim's admission date matches its From date before it pays the add-on, and it may return a claim that qualifies for the add-on but has no qualifying skilled visit. A LUPA claim doesn't pay non-routine supplies on top of the visits.

If a visit your clinician made was left off the claim, adjust the claim. The Claims Processing Manual says that when the adjusted count reaches the threshold, payment moves from a per-visit basis to the payment group's rate.

A partial payment adjustment applies when your patient transfers to another agency inside the 30 days, or is discharged with goals met and comes back to you inside them. You mark the claim with patient status code 06, and Medicare pays the share of 30 days from the first billable visit to the last. Transfers between agencies under common ownership don't get one, unless the patient moved to a different wage area during the period before the transfer.

The HHS Office of Inspector General audited 2017 claims, when four or fewer visits made a 60-day episode a LUPA, and sampled 120 with five to seven visits. Twenty-five didn't meet Medicare requirements. OIG estimated $191.8 million in overpayments nationwide and found that 20 of the 25 would also have been out of compliance under PDGM.

OIG concluded that even under PDGM, claims with visits slightly above the threshold still carry a significant risk of improper payment. CMS concurred with its recommendations, including having its contractors analyze those claims and target them for additional review.

The plan of care sets the visit count. The rule asks for the frequency and duration of visits, tied to the needs found in the comprehensive assessment. A practitioner can order a range, such as two to three visits a week; in the rule's words, "the upper limit of the range is considered the specific frequency." An "as needed" order has to say which signs call for the visit and cap how many.

When the patient's needs change, the plan changes with them. You're required to alert the practitioner promptly when the patient's condition suggests the plan should be altered, and the plan is reviewed as often as the patient's condition or needs require, and at least every 60 days.

The periods worth a second look are the ones where the record and the claim disagree: a visit the plan ordered that didn't happen and wasn't explained, or a visit on the claim with nothing in the note showing why the patient needed it.

These checks, their monthly timing and the samples are our suggestions, not CMS rules; CMS sets the thresholds, the per-visit rates and add-on, and what the plan of care must hold.

1. List last month's LUPA periods. Note each one's group, threshold, visits made and why it came in short.
2. Check admission dates on first-period LUPAs.
3. Match visit notes to claim lines on a sample.
4. Read a sample of periods that land exactly on the threshold.
5. Read every missed visit against the plan. Confirm the practitioner was told and the plan was changed if the need changed.

Enzo is a home health EHR.

Do telehealth visits count toward the threshold?

No. The plan of care rule says telehealth services "cannot be considered a home visit for the purposes of patient eligibility or payment." You still report them on the claim, as you have since July 1, 2023: video visits (G0320), audio-only visits (G0321) and remote patient monitoring (G0322). A billing period with only telehealth isn't submitted to Medicare, and telehealth has to be written into the plan of care, tied to needs the assessment found, and can't stand in for a home visit the plan ordered.