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Published: 2021-08-31
David Edelstein
Centers for Medicare & Medicaid Services Patient-Driven Groupings Model - Overview of the Patient-Driven Groupings Model 10-2018.pdf
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. Each of the 432 different PDGM payment groups has a threshold that determines if the 30-day period receives this Low-Utilization Payment Adjustment (LUPA). For each payment group, the 10th percentile value of visits is used to create a payment group specific LUPA threshold with a minimum threshold of at least two for each group. A 30-day period with a total number of visits below the LUPA threshold are paid per-visit rather than being paid the case-mix adjusted 30-day payment rate. A 30-day period with a total number of visits at or above the LUPA threshold is paid the case- mix adjusted 30-day payment rate rather than being paid per-visit
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