Missed Visit
A missed visit is a visit ordered on the home health plan of care that was not delivered as scheduled, whether because the patient refused or was unavailable, the agency could not staff it, or the visit could not safely occur. Because Medicare requires care to follow the ordered frequency, every missed visit needs documentation, follow-up, and, per agency policy, practitioner notification, and enough of them can push a 30-day period into LUPA territory.
What counts as a missed visit
A visit is missed when it was due under the ordered frequency and did not happen. Common causes split into patient-driven (refusal, not home, hospitalization, family events, weather at the patient's request) and agency-driven (staffing shortfalls, scheduling errors, clinician callouts without backfill, drive-time failures). The distinction matters. Patient-driven misses are a documentation and care-continuity issue. Agency-driven misses are that plus an operational failure surveyors and reviewers read as the agency not following its own plan of care, and a pattern of them is a Conditions of Participation problem.
Required documentation and follow-up
Every missed visit should generate a record that answers four questions: what visit was missed and why, who was notified, what was done to recover the care, and how the plan changes. Good practice, and typical agency policy, includes:
- A missed visit note the same day with the specific reason
- An attempt to reschedule within the ordered frequency window
- Notification to the certifying practitioner when the miss affects the plan of care, with an order if frequency changes
- Case manager review for repeated refusals, which may signal a competency, engagement, or discharge conversation
Repeated patient refusals deserve special attention: they undermine the skilled-need narrative and may warrant a discharge discussion rather than indefinite documentation of misses.
The PDGM and quality stakes
Under PDGM, each 30-day period has a LUPA threshold of 2 to 6 visits depending on its case-mix group. A period sitting one or two visits above threshold can flip to per-visit LUPA payment on the strength of a couple of missed visits, often costing the agency more than a thousand dollars per occurrence. Missed visits also degrade the outcomes that drive the expanded HHVBP model: skipped early visits correlate with hospitalization, and hospitalization sits in the claims-based measures worth 40% of the Total Performance Score. Agencies should track missed visit rate by reason code, clinician, and day of week, because the fix differs depending on whether the driver is refusals or staffing.
Common pitfalls
The recurring failures: missed visits documented days later or not at all, generic reasons ("patient unavailable") that make patterns invisible, no practitioner notification despite policy requiring it, schedules quietly rebuilt around chronic Friday callouts instead of fixing coverage, and no one watching LUPA-fragile periods so a single miss converts the claim. The operational fix is a daily exception report: every ordered-but-undelivered visit surfaces to scheduling and the case manager the same day, with LUPA-fragile periods flagged for priority recovery.
Frequently asked questions
Does Medicare require physician notification for every missed visit?
Medicare does not spell out a per-miss notification rule; it requires care to follow the plan of care and agencies to have policies. Most agency policies require practitioner notification when misses affect the ordered frequency or the patient's condition, and surveyors hold agencies to their own policy.
Can a missed visit cause a LUPA?
Yes. If missed visits drop the total delivered visits in a 30-day period below that period's LUPA threshold, the claim pays per visit instead of the full case-mix rate. Periods running close to threshold should be flagged so recovery visits get priority.
What should we do about a patient who repeatedly refuses visits?
Document each refusal and the education provided about risks, notify the practitioner, and address barriers (timing, aide preferences, caregiver schedules). If refusals persist and the ordered care cannot be delivered, the team should consider a plan of care revision or discharge, since continuing to bill an episode the patient will not participate in is a compliance risk.