Author: Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ, ACPA-C | September 29, 2026
Medicare Advantage has traditionally occupied a familiar space in hospital operations: prior authorization, utilization management, denials, risk adjustment, and reimbursement. With the FY 2027 Inpatient Prospective Payment System final rule, healthcare organizations need to add another significant area to that list—hospital mortality performance.
The Centers for Medicare & Medicaid Services (CMS) finalized modifications to five existing 30-day, all-cause, risk-standardized mortality measures to include eligible Medicare Advantage beneficiaries in addition to traditional Medicare fee-for-service beneficiaries. The affected measures are acute myocardial infarction (AMI), heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and coronary artery bypass graft (CABG) surgery. CMS also finalized shortening the performance period for these modified measures from three years to two years. ¹˒²
The modified measures will begin in the Hospital Inpatient Quality Reporting (IQR) Program with the FY 2028 payment determination, with CMS also finalizing their adoption into the Hospital Value-Based Purchasing (VBP) Program beginning with the FY 2032 program year. ¹ This should not be viewed simply as another Quality department reporting change. It creates an enterprise issue involving Quality, clinical documentation integrity (CDI), utilization review (UR), case management, HIM and coding, physician advisors, compliance, analytics, revenue cycle, and executive leadership.
Most importantly, hospitals should not look at FY 2028 or FY 2032 and assume there is plenty of time to prepare. Quality measures are retrospective. By the time a hospital sees an unfavorable publicly reported result, the encounters that produced it may be well behind it. Understanding your current Medicare Advantage mortality population now builds confidence in leadership’s proactive approach.
Why Medicare Advantage changes the mortality picture
Medicare Advantage now represents more than half of the Medicare population, and CMS specifically identified the growing proportion of Medicare beneficiaries enrolled in MA as part of its rationale for expanding these claims-based measures. CMS expects inclusion of MA beneficiaries to provide a more representative picture of outcomes across the Medicare population. ¹
This creates an important challenge for hospitals because traditional Medicare and Medicare Advantage patients may travel through very different operational workflows. An MA admission may receive significant attention from UR because of payer authorization requirements, concurrent review, level-of-care determinations, peer-to-peer discussions, and denial risk. The same patient may be evaluated through a risk-adjustment lens, while Quality departments have historically managed CMS mortality measures according to the populations defined by each measure’s specifications.
Those distinctions become increasingly difficult to maintain when the same medical record can influence utilization management, risk adjustment, coding, reimbursement, mortality measurement, public reporting, and eventually value-based purchasing. CMS is widening the population included in these measures. Hospitals need to widen their internal view as well.
Five populations need attention now.
The five modified measures cover AMI, heart failure, pneumonia, COPD, and CABG. ¹ These are 30-day, all-cause, risk-standardized mortality measures. Risk standardization is an essential part of this discussion because hospitals do not care for identical populations. A tertiary or quaternary referral center managing highly complex patients cannot reasonably be evaluated as though its patients have the same baseline mortality risk as every other hospital population. CMS uses risk adjustment to account for defined differences in patient characteristics when calculating these measures. ³
That makes the integrity of the underlying clinical record important, but it also requires discipline in how hospitals respond. Documentation cannot change the fact that a patient died. Accurate documentation can help ensure that the administrative data derived from the record appropriately represents the patient’s clinical condition and supported risk factors.
This distinction is critical. The response to these measures cannot become an initiative to capture more diagnoses or make Medicare Advantage patients appear sicker. The goal must be an accurate and clinically defensible representation of the patient. Engaging CDI, Coding, and Quality teams early fosters a sense of shared purpose and commitment.
What CDI should examine
CDI leaders should determine whether current review prioritization creates an unintended Medicare Advantage blind spot. Many programs prioritize cases according to reimbursement opportunity, payer, DRG, diagnosis, length of stay, technology-generated prioritization, or other organizational objectives. Those approaches may be appropriate for their intended purpose, but expanding these mortality measures raises another question: Are the Medicare Advantage patients who will influence Quality outcomes consistently reaching CDI?
Organizations should begin with the five affected populations and compare CDI review penetration for MA and traditional Medicare patients. Review query patterns, response rates, principal diagnosis selection, present-on-admission determinations, clinically supported secondary diagnoses, clinical validation findings, and post-discharge coding changes. The objective is not to achieve identical query rates between payer populations. The goal is to identify unexplained variation and determine whether workflow design, rather than clinical differences, is responsible.
CDI also needs to understand the actual measure specifications. A diagnosis that changes an MS-DRG does not automatically affect mortality risk adjustment, just as a condition relevant to a quality methodology may not change reimbursement. Clear understanding of these details reassures teams that their efforts are meaningful and precise.
UR and case management cannot be left out.
UR’s role differs from CDI’s but is equally important. Medicare Advantage patients already generate substantial UR activity because of authorization requirements, concurrent reviews, medical necessity determinations, payer communication, and denials. Mortality changes create an opportunity to connect those workflows to clinical outcomes and transitions of care.
Thirty-day mortality does not end at hospital discharge. Case management and UR leaders should evaluate whether MA patients experience different barriers to post-acute care than traditional Medicare patients. Are skilled nursing facility placements delayed? Are home health services difficult to obtain? Do network restrictions limit available post-acute providers? Are authorization processes delaying transitions? Are high-risk patients leaving the hospital without timely physician follow-up or other necessary services?
Those questions matter because documentation accuracy represents only one part of mortality performance. Clinical care, discharge planning, and successful transitions make up the rest. A perfectly documented risk profile cannot compensate for a preventable failure in transition of care.
Quality needs to change the denominator.
Quality departments should determine whether existing mortality dashboards and case-review processes currently include Medicare Advantage beneficiaries in a way that approximates the modified CMS measures. If they do not, organizations should begin developing that capability now rather than waiting for CMS results.
I would recommend creating separate views for traditional Medicare and Medicare Advantage before creating a combined view. Organizations should examine mortality trends, service line, physician group, discharge disposition, hospice and palliative care patterns, transfers, and transitions of care. They should then determine whether differences represent clinical variation, documentation variation, coding differences, workflow issues, data problems, or some combination of these factors.
CMS also finalized shortening the performance period for the modified measures from three years to two. CMS stated that the shorter period is intended to make results more reflective of recent hospital performance and provide more actionable information for quality improvement. ¹ For hospitals, that also means organizations have less time for older performance to be diluted by later improvement. Identifying problems and implementing effective interventions becomes even more important.
Compliance needs to protect the integrity of the response
Whenever quality performance, public reporting, documentation, and reimbursement intersect, compliance should be involved early. Organizations need clear guardrails around how these measures are addressed.
Queries must remain clinically supported, compliant, and non-leading. Diagnoses should not be encouraged simply because they may improve expected mortality or another risk-adjusted outcome. Coding must continue to follow the ICD-10-CM Official Guidelines for Coding and Reporting and applicable coding guidance. Present-on-admission indicators must accurately reflect the record, and clinical validation standards should not change depending on whether a diagnosis improves or worsens expected mortality.
Compliance should also evaluate retrospective mortality-review processes. If an organization begins reviewing deaths after discharge and subsequently generates significantly more retrospective queries, leadership should evaluate whether the process is clinically appropriate, consistently applied, and aligned with organizational query policies. The goal must remain an accurate clinical record—not a favorable mortality score.
The C-suite needs a single governance structure.
This policy change should not result in Quality creating one workgroup, CDI creating another dashboard, UR developing another workflow, and Finance learning about the issue after performance results appear. Executive leadership should establish a unified governance structure for these populations.
At minimum, that structure should include Quality, CDI, HIM and Coding, UR, case management, physician advisors, compliance, analytics, managed care, revenue cycle, and physician leadership. The group should be able to answer several basic questions: Do we know our Medicare Advantage mortality performance for these five populations? How does it compare with traditional Medicare? Are the same patients represented consistently across Quality, CDI, Coding, and UR data? Are Medicare Advantage claims and encounter data complete and aligned with the final coded record? Are there unexplained documentation or coding differences by payer? Are deaths reviewed consistently? And when an opportunity is identified, who owns the intervention?
Without defined governance, organizations risk treating one patient as several different datasets. Quality may identify an outcome issue, CDI may see a documentation opportunity, UR may recognize a transition barrier, and Coding may identify a data discrepancy without anyone connecting the findings.
What hospitals should monitor now
Hospitals should consider building a Medicare mortality readiness dashboard around four domains: population, documentation and data integrity, clinical outcomes, and process reliability.
Population monitoring should include MA and traditional Medicare volume for AMI, heart failure, pneumonia, COPD, and CABG, along with deaths and applicable measure exclusions. Documentation and data-integrity monitoring should examine CDI review penetration, query patterns, principal diagnosis selection, POA accuracy, clinically supported comorbidity capture, coding changes, and reconciliation between the final coded record and downstream data.
Clinical outcome monitoring should include mortality trends, discharge disposition, transitions of care, relevant readmissions, hospice and palliative care patterns, and service-line variation. Process reliability should address whether deaths receive appropriate multidisciplinary review, whether identified opportunities result in action, and whether interventions produce sustained improvement.
Importantly, MA and traditional Medicare should be stratified initially rather than combined immediately. A single aggregate result can conceal significant variation between populations. If mortality differs, organizations need to understand why before assuming documentation is the problem.
What needs to change now
The response does not require another isolated initiative. It requires alignment of work hospitals are already doing.
CDI should expand its quality lens beyond reimbursement-driven prioritization and determine whether MA patients in the five mortality populations are consistently reviewed. UR and case management should connect MA utilization workflows with post-acute access, discharge planning, and transitions-of-care analysis. Quality should incorporate MA patients into mortality surveillance and multidisciplinary case review. HIM and Coding should assess whether coding practices and data integrity are consistent across payer populations. Compliance should establish clear guardrails for queries, retrospective review, and risk-adjustment activities. Analytics should create a common source of truth rather than allowing multiple departments to generate competing versions of mortality performance. Physician leaders should help distinguish documentation opportunities from genuine clinical-care opportunities.
The C-suite must ultimately hold itself accountable for the entire process. Mortality performance cannot belong exclusively to Quality when the data driving it span clinical care, documentation, coding, utilization management, transitions of care, and reimbursement.
One patient, one record, multiple consequences
Perhaps the most important change is culture. Healthcare organizations have spent years dividing the medical record according to who needs it. CDI sees documentation. Coding sees classification. UR sees medical necessity. Quality sees outcomes. Finance sees reimbursement. Compliance sees risk.
The patient has only one record.
CMS is increasingly using that record across multiple dimensions of healthcare performance. The organizations best prepared for Medicare Advantage’s inclusion in mortality measurement will not be those that discover more diagnoses. They will be the organizations that connect clinical care, documentation, coding, utilization management, quality measurement, data integrity, and compliance into one accurate and defensible representation of the patient.
Medicare Advantage is now entering the mortality equation. This is no longer merely a proposal to watch. CMS has finalized the policy, and the appropriate response is not to wait for future public reporting to tell us whether there is a problem.
Hospitals should know their five populations now. They should know whether MA and traditional Medicare patients look different, whether documentation and coding practices are consistent, whether transitions of care differ, and whether the data reaching CMS accurately reflects the care delivered.
The question is no longer whether hospitals need to prepare. The question is whether we are already looking at the right patients, with the right teams, through the same lens.
References
- Centers for Medicare & Medicaid Services. FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final Rule. 2026.
https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-long-term-care-hospital-prospective-payment
- Centers for Medicare & Medicaid Services. FY 2027 IPPS Final Rule Home Page. CMS-1849-F. 2026.
https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2027-ipps-final-rule-home-page
- Centers for Medicare & Medicaid Services. Outcome and Payment Measures.
https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/outcome-and-payment-measures
- Health Information Partners. Medicare Advantage Data Could Soon Hit Your Hospital’s Quality Scores. Are You Ready? 2026. https://hip-inc.com/medicare-advantage-mortality-measures/
This article was originally published on RACmonitor.
