PDGM · Billing
LUPA Threshold Checker
Enter a HIPPS code or pick a case-mix group — see the CY2026 LUPA visit threshold, case-mix weight, and how many more visits clear it.
CY2026 PDGM · CMS-1828-F · ingested 2026-04-28
The 5-character code from a 30-day claim (e.g., 1FC11).
Try an example:
How many visits are completed or scheduled for this 30-day period? We'll show how many more clear the threshold.
Enter a HIPPS code to see its LUPA threshold.
Frequently asked questions
- What is a LUPA in home health?
- A LUPA (Low-Utilization Payment Adjustment) is what CMS pays instead of the full 30-day case-mix rate when a home health period has fewer completed visits than that case-mix group's LUPA threshold. Instead of the case-mix payment, Medicare pays the national per-visit rate for each visit actually completed — usually far less than the full episode rate (42 CFR §484.230).
- How many visits avoid a LUPA in 2026?
- It depends on the case-mix group — across the 432 CY2026 HIPPS case-mix groups, thresholds range from 2 to 5 visits per 30-day period (CMS recalibrates these every year, and the design allows up to 6). Look up the specific HIPPS code or case-mix group above to see its exact threshold; completing that many visits (or more) in the period avoids the LUPA and pays the full case-mix rate.
- Does the LUPA threshold change per case-mix group?
- Yes. Every one of the 432 CY2026 PDGM case-mix groups — the combination of admission source, timing, clinical group, functional level, and comorbidity adjustment — has its own LUPA threshold and case-mix weight, recalibrated annually in the HH PPS Final Rule (CMS-1828-F). There is no single threshold that applies agency-wide.
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