Proposed rule update for hospital leaders
The Centers for Medicare & Medicaid Services (CMS) has proposed expanding five hospital 30-day Medicare Advantage mortality measures by adding eligible MA beneficiaries to existing cohorts. Medicare Advantage (MA) is the private-plan alternative to traditional Medicare. If finalized, MA data may influence quality measurement, hospital comparisons, and value-based purchasing mortality performance. Begin evaluating operational readiness now while monitoring the final FY 2027 IPPS rule.
Key Takeaways
- CMS proposes adding eligible MA patients to five existing 30-day mortality measures for AMI, HF, pneumonia, COPD, and CABG.
- The proposed performance period is July 1, 2024–June 30, 2026, tied to FY 2028 payment determination.
- MA data could affect quality measurement, public comparisons, and value-based purchasing mortality results.
- Consistent documentation and coding across MA and traditional Medicare cases are essential for accurate risk adjustment.
- Hospitals should assess workflows, governance, and monitoring now to avoid avoidable variation if the rule is finalized.
What does the FY 2027 IPPS proposal change for mortality measures?
CMS FY 2027 IPPS Proposed Rule | Client Alert
This is a proposed rule—not a final requirement. Hospitals should monitor the final FY 2027 IPPS rule and begin assessing operational readiness now.
CMS has proposed to modify five established hospital 30-day mortality measures by expanding the patient population to include eligible Medicare Advantage (MA) beneficiaries, in addition to Medicare fee-for-service beneficiaries. The proposed measures involve:
| Proposed modified mortality measure | Proposed performance period | Proposed payment determination |
|---|---|---|
| Acute myocardial infarction (AMI) | July 1, 2024–June 30, 2026 | FY 2028 |
| Heart failure (HF) | July 1, 2024–June 30, 2026 | FY 2028 |
| Pneumonia | July 1, 2024–June 30, 2026 | FY 2028 |
| Chronic obstructive pulmonary disease (COPD) | July 1, 2024–June 30, 2026 | FY 2028 |
| Coronary artery bypass graft (CABG) | July 1, 2024–June 30, 2026 | FY 2028 |
CMS describes the proposal as a step toward substantively modifying the mortality measures currently used in the Hospital Value-Based Purchasing Program.
Why could Medicare Advantage data affect hospital quality scores?
Why this matters now
For many organizations, MA coding has been managed primarily through the lenses of risk adjustment, payer contracts, denials, and claims accuracy. Under this proposal, MA data could have a broader role: it may contribute to hospital quality measurement, public performance comparisons, and value-based purchasing-related mortality performance.
The practical message is simple: documentation and coding consistency across Medicare populations may become a quality-performance issue—not only a reimbursement issue.
What exactly is proposed for Medicare Advantage mortality cohorts?
1. Medicare Advantage patients would enter selected mortality cohorts
The five proposed measure modifications would add eligible MA beneficiaries to the existing AMI, HF, pneumonia, COPD, and CABG mortality measures. This increases the importance of complete, accurate, and timely hospital-submitted MA claims and encounter data.
2. Performance periods would be shorter
CMS proposes a July 1, 2024–June 30, 2026 performance period for the five modified mortality measures, associated with FY 2028 payment determination. A shorter performance period can make results more sensitive to changes in case mix, documentation consistency, mortality review practices, and data integrity.
3. Risk adjustment depends on reliable clinical documentation and coding
CMS quality measures use claims-based data and risk adjustment to account for differences in patient case mix. Conditions documented as present on admission, along with prior claims history and other approved risk variables, can affect cohort construction and risk adjustment.
Documentation specificity does not “improve” a patient’s outcome. It improves the accuracy of the data used to compare hospitals caring for different levels of patient complexity.
How should HIM and CDI leaders respond?
The HIM and CDI impact
Documentation consistency is now a cross-functional issue
If a hospital applies robust CDI and coding review to traditional Medicare mortality cases but not to MA cases, the organization may create avoidable variation in its quality data. The same clinical record can influence multiple downstream processes.
| Workflow area | Key question for leadership |
|---|---|
| CDI | Are MA inpatient cases receiving the same review criteria and query governance as comparable traditional Medicare cases? |
| Coding | Are principal diagnosis, POA, secondary diagnosis, CC/MCC, and severity-related coding practices consistent across payer populations? |
| Quality | Are MA cases included in mortality-review workflows, dashboards, and root-cause analysis processes? |
| Case management | Are transition-of-care risks identified consistently, regardless of Medicare enrollment type? |
| Revenue integrity/risk adjustment | Do retrospective reviews align with the final coded record used for quality measurement? |
What key documentation and coding areas deserve early review?
- Principal diagnosis selection: Ensure the condition chiefly responsible for admission is clearly supported and consistently coded.
- Present-on-admission (POA) documentation: POA status can be important to measure methodology and risk adjustment; confirm provider documentation supports accurate reporting.
- Comorbidity capture: Chronic conditions, acute conditions present on admission, and clinically significant complications should be documented and coded only when supported by the record and applicable reporting rules.
- Mortality review alignment: Review whether MA deaths in the affected cohorts receive the same clinical, documentation, coding, and quality checks as traditional Medicare cases.
- Data flow integrity: Confirm that hospital-submitted MA claims and encounter data are complete, timely, and aligned with the final coded record.
What is a practical readiness roadmap for this proposal?
A practical readiness roadmap
1. Identify the population
Create a baseline inventory of MA inpatient volume, mortality, and case mix for AMI, HF, pneumonia, COPD, and CABG. Separate this from—but compare it with—traditional Medicare performance.
2. Compare workflows and data
Assess differences between MA and traditional Medicare cases in CDI review rates, query rates, coding turnaround, POA completion, late coding changes, mortality-review inclusion, and final claim submission processes.
3. Align governance
Bring CDI, HIM/coding, quality, clinical documentation integrity, case management, utilization review, revenue integrity, managed care, and analytics together around a common review framework. The goal is not duplicate review; it is a coordinated process that produces one accurate, defensible final record.
4. Monitor early
Develop a dashboard that tracks MA and traditional Medicare performance separately and together. Look for differences in diagnosis capture, mortality trends, excluded cases, data-submission timing, and high-risk documentation patterns.
What should hospital leaders be asking now?
Questions for hospital leaders
- Do our mortality-review processes currently include MA patients in the same manner as traditional Medicare patients?
- Are MA claims and encounter submissions complete and reconciled to the final coded discharge record?
- Do CDI and coding practices vary by payer, product line, or review workflow?
- Are POA, principal diagnosis, and risk-adjustment-relevant secondary diagnoses consistently documented and coded when clinically supported?
- Who owns cross-functional accountability when a case affects quality, coding, payer, and risk-adjustment processes simultaneously?
How HIP can help before the final rule
HIP perspective
This proposal underscores the need to move away from payer-specific documentation silos. A single inpatient record may now affect mortality review, quality reporting, coding accuracy, payer relations, risk adjustment, and organizational performance.
Health Information Partners can help organizations assess affected Medicare Advantage populations, compare coding and CDI workflows, evaluate mortality-review integration, and establish practical governance and monitoring processes before final-rule implementation.
Frequently Asked Questions
Which mortality measures would include Medicare Advantage patients?
The proposal adds eligible Medicare Advantage beneficiaries to five established 30-day mortality measures: acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), and coronary artery bypass graft (CABG). These are existing measures that currently use Medicare fee-for-service data.
What is the proposed performance period and payment year?
CMS proposes a performance period of July 1, 2024–June 30, 2026 for the modified measures, with FY 2028 payment determination. Hospitals should monitor the final FY 2027 IPPS rule for any changes.
How could Medicare Advantage data affect quality and VBP results?
Under the proposal, MA data may contribute to hospital quality measurement, public performance comparisons, and value-based purchasing mortality performance. CMS also describes this as a step toward substantively modifying mortality measures used in the Hospital Value-Based Purchasing Program.
Why does documentation and coding consistency matter here?
CMS mortality measures use claims-based data and risk adjustment to reflect differences in patient case mix. Consistent POA status, principal diagnosis selection, and clinically supported comorbidity capture improve the accuracy of comparisons across hospitals.
What should hospitals do now to prepare?
Begin by identifying affected MA cohorts, comparing MA vs. traditional Medicare workflows and outcomes, aligning cross-functional governance, and monitoring early with dashboards. Focus on data completeness, mortality-review inclusion, and documentation patterns that influence risk adjustment.
Source note
This article summarizes provisions in the CMS FY 2027 IPPS proposed rule. CMS proposed five modified 30-day mortality measures for AMI, HF, pneumonia, COPD, and CABG; each has a proposed July 1, 2024–June 30, 2026 performance period associated with FY 2028 payment determination. The proposal remains subject to change in the final rule.
By Teresa Whitten, RHIT, CCS | Facility Coding Supervisory and Lela Olilla, MBA, RHIA, CDIP, CCS, CPCO | VP of Facility Services