Posts Tagged ‘LUPA Rates’

Summary of the CMS Released 2013 Final Rule

Tuesday, November 27th, 2012

Market Basket and Payment Rate Update

On November 2, 2012, CMS released the Medicare Home Health Final Rule for the Home Health Prospective Payment System 2013. The proposal includes the 2013 Market Basket Index (MBI) update of 2.3%, the required 1 point reduction under the Obama Affordable Care Act, and the reduction in rates of 1.32%, which is approximately a $10M decrease to payments for the home health 60 day episodes for 2013. The main change, per NAHC, from the July 5th proposed rule adjustment is an adjustment of the MBI from 2.5 to 2.3% occurring as a result of more current data. Proposed payment base episode rates are set at $2137.73 from a current $2138.52.

Though a small increase, the gain is that it is not the decrease CMS had proposed if  a full creep adjustment had been incorporated. The base rates are adjusted up by 3% for service to patients in rural areas.



For agencies submitting the required quality data, the LUPA rates are :

HH Aide $  51.79

MSS       $ 183.31

OT          $ 125.88

PT           $ 125.03

SLP        $  135.86

SN          $  114.35


For those agencies that have not submitted quality data, their rates will be reduced by 2 percentage points.


The outlier eligibility standards are changed from 2012. The Fixed Dollar Loss Ratio is lowered from 0.67 to 0.45. This will increase the number of episodes that will qualify for outlier payment.



Home Health agencies should expect payments subjected to a 2% sequestration, as part of the deficit reduction law. Though this is not a rate change, in and of itself, it will be a withhold of 2% from the claims payment. This is another  home health  reduction. Be prepared for expected significant changes for 2014 when CMS rebases the HHPPS rates as required under the Affordable Care Act.



CMS finalized three revisions regarding qualified therapists completing a functional reassessment of the patient at the 14th and 20th visit and every 30 days.


First: CMS states that if a qualified therapist misses a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, NOT the visit after the qualified therapist completed the late reassessment.


Second: CMS states that in cases where there is multiple therapy disciplines involved, if the required reassessment by the qualified therapist was missed for any of the therapy disciplines, therapy coverage would cease for only the therapy discipline involved.


Third: CMS states that in cases where the patient is receiving more than one type of therapy, qualified therapist must complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and they must complete the 19th visit reassessment during the 17th, 18th, or 19th visit. CMS also states that in instances where the beneficiary receives more than one therapy type, if the frequency of a particular discipline does not make it feasible for the reassessment to occur during the specified times without providing an extra unnecessary visit or would delay a needed visit, then it is acceptable for the qualified therapist from each discipline to provide all of the therapy and functionally reassess the beneficiary during the visit associated with the discipline that is scheduled to occur closest to the 14th Medicare covered therapy visit, but no later than the 13th Medicare covered visit. Likewise for the 20th Medicare covered therapy visit but no later than the 19th covered therapy visit.


Thus, the revised rule states that if, in multiple therapy visit cases, the required reassessment was missed for any of the therapy disciplines, therapy coverage would cease only for that particular therapy. Therefore, as long as the required therapy assessments are completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines, unlike presently.


Face to Face

CMS finalized adjustments allowing non-physician practitioners in an inpatient setting to perform the encounter and inform the inpatient physician who can then become the certifying physician.



M1024, effective January 1, 2013, is to only be used for acute fracture codes for case mix points. Patient resolved conditions are not to be coded in home health. Citing Attachment D, CMS has clarified the only codes not allowed in homecare are acute fractures. These, then will be the only resolved codes allowed in M1024. Neoplasms, diabetes codes, neuro codes, and skin will no longer garner case mix points if placed in M1024, although CMS has stated an agency may continue to place resolved conditions in M1024 to present a more complete picture of the patient.


The final rule can be found at