Home health

The 30-day period: PDGM case-mix weight, LUPA visit test and wage index.

Period

30-day period of care

Build the code from its parts

The agency’s code comes from its OASIS assessment and the claim’s diagnoses; this only spells the code out. All 432 combinations are payment groups.

A CBSA is the metro area (or a state’s rural area) the claim reports in value code 61. LUPA, a low-utilization payment adjustment: a period with fewer visits than its group’s threshold, 2 to 5 visits, is paid per visit instead.

Payment

Checks

What this pricer does not do

  • It does not assign the HIPPS code. The code is an input: grouping from the OASIS assessment and the claim’s diagnoses is not done here.
  • It does not price a LUPA period. A period with fewer visits than its group’s threshold is flagged, not priced: per-visit rates are not loaded.
  • No partial period payment, for a patient who moves to another agency or is discharged and readmitted to the same agency within the 30 days.
  • No outlier payment for an unusually costly period.
  • No agency-level adjustments, such as the home health value-based purchasing adjustment, and no sequestration.
  • CY2026 rates only: periods in other years are flagged and priced at the 2026 rate.

How Medicare pays a home health period

Medicare pays a home health agency a fixed amount for each 30-day period of care, under the Patient-Driven Groupings Model (PDGM). The HIPPS code on the claim names one of 432 payment groups. Its five characters say whether the period is early (the first 30-day period of a run of care) or late (any later one), whether the patient came from the community or after a recent hospital or post-acute stay, which of 12 clinical groups the primary diagnosis falls in, the patient’s functional impairment level (low, medium or high), and the comorbidity adjustment (none, low or high). The last character is always 1.

Each group has a case-mix weight. For CY2026 the national 30-day rate is $2,038.22. It is multiplied by the weight, and the labor share of the result, 74.9%, is multiplied by the wage index of the area where the care was given (the CBSA code in value code 61 on the claim); the other 25.1% is paid as is. An agency that did not report its required quality data has its annual update cut by 2 percentage points, so its 30-day rate is $1,998.41. For example, HIPPS 1FC11 (an early period from the community, behavioral health, high functional impairment, no comorbidity adjustment, weight 1.0804) in the Houston area (CBSA 26420, wage index 0.9729) pays $2,157.40.

Each group also has a visit threshold, from 2 to 5 visits. A period with fewer visits than its group’s threshold is a low-utilization payment adjustment (LUPA): it is paid per visit instead of the 30-day amount. This pricer flags a LUPA period and does not price it.

Questions

Why the wage index of where the care was given, not the agency’s office?

Home health is paid on the wage index of the place of service, which the claim reports as the CBSA code in value code 61. An agency serving patients in more than one area is paid a different amount for the same group in each area.

What is a LUPA?

A low-utilization payment adjustment. When a 30-day period has fewer visits than its group’s threshold, Medicare pays for each visit by discipline instead of the period amount. The threshold depends on the group: 2, 3, 4 or 5 visits.

Can this pricer work out the HIPPS code?

No. The code comes from the agency’s OASIS assessment, the claim’s diagnoses and the period’s timing and admission source. Enter the code on the claim, or spell it out from its parts with Build the code.

What is left out?

Per-visit LUPA payments, partial period payments, outlier payments, the value-based purchasing adjustment and sequestration. The figure is the 30-day period amount for the HIPPS code and area you enter.