Advance care planning has always been personal. It is one of the most human conversations that occurs in healthcare. It asks patients, families, caregivers, and clinicians to talk about goals, values, fears, treatment preferences, and what should happen if the patient is no longer able to speak for themselves.
But advance care planning is also becoming something else: quality data.
In the FY 2027 IPPS/LTCH PPS proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposes adopting an Advance Care Planning electronic clinical quality measure, or eCQM, beginning with the FY 2030 payment determination. CMS also proposes adopting the same eCQM in alignment with the Medicare Promoting Interoperability Program and adopting an Advance Care Planning eCQM for the PPS-Exempt Cancer Hospital Quality Reporting Program beginning with the FY 2030 program year. [1]
That may sound like a future quality reporting update, but hospitals should not treat it as a distant technical requirement. It signals something larger: the patient’s preferences, goals of care, surrogate decision-maker information, advance directive status, and documented care-planning conversations are moving further into the world of structured data, interoperability, validation, and quality accountability.
For clinical documentation integrity, coding, quality, compliance, informatics, and provider leaders, this is the moment to ask a basic but important question: if an advance care planning conversation happens, can the record clearly prove it?
Advance Care Planning Is More Than a Form
CMS describes advance care planning as a voluntary, face-to-face discussion between a clinician and the patient, family member, caregiver, or surrogate, as appropriate, to discuss the patient’s healthcare wishes if the patient becomes unable to make their own medical decisions. The discussion may include advance directives, with or without helping the patient complete legal forms. [2]
The Important Difference
Too often, healthcare teams think of advance care planning as a checkbox: advance directive on file, yes or no; code status, full code or DNR; POLST completed, yes or no. Those elements are important, but they do not always tell the full clinical story.
A meaningful advance care planning note should make clear what was discussed, who participated, what the patient understood, what preferences were expressed, whether a surrogate decision-maker was identified, whether existing documents were reviewed, and whether the care team’s plan aligns with the patient’s stated goals.
This is where documentation integrity becomes essential. The issue is not to turn a deeply personal conversation into a compliance exercise. The issue is to ensure that when patients do share their wishes, those wishes are visible, retrievable, understandable, and usable by the next clinician who needs them.
The eCqm Lens Changes the Operational Expectation
According to the eCQI Resource Center, the hospital-level Advance Care Planning eCQM is a patient-based measure that evaluates the proportion of eligible patients who have advance care planning sufficiently documented in the medical record. The initial population includes patients 18 years of age and older with a discharge from an acute care hospital or critical access hospital inpatient setting during the measurement period. [3]
The numerator can be satisfied by documentation of an advance care planning document, such as a healthcare agent, advance directive, living will, or portable medical order; documentation of a DNR order coded during the inpatient encounter using ICD-10-CM code Z66; or documentation that an advance care planning discussion resulting in a decision occurred during the inpatient encounter. [3]
That means hospitals will need to think beyond narrative documentation alone. The conversation may occur in a progress note, palliative care note, social work note, admission history, discharge planning note, or goals-of-care note. But if the information is buried, inconsistent, or stored in a non-discrete location, it may not be captured correctly for quality measurement.
This creates a new documentation integrity challenge: the record must be clinically meaningful to the care team and technically usable for quality reporting. Those are not always the same thing.
A beautifully written narrative note may tell the human story, but if key data elements are not mapped, coded, or captured in the correct EHR field, the quality measure may not recognize that the work occurred. On the other hand, a checked box may satisfy a data field but fail to communicate the substance of the patient’s goals and preferences. Hospitals need both.
The Patient Safety Issue
Advance care planning documentation is not only about payment determination or reporting. It directly affects care continuity. When a patient deteriorates, transfers units, returns through the emergency department, or is discharged to another care setting, the record should clearly communicate the patient’s wishes and the decision-making structure.
Who is the legal surrogate? Is there a healthcare agent? Are there advance directive documents? Are they current? Did the patient express limits on treatment? Did the patient want all life-sustaining interventions, a time-limited trial, comfort-focused care, or treatment aligned with a specific functional goal? Was the discussion with the patient, the family, the caregiver, or a legally authorized representative? These are not abstract data points. They influence real clinical decisions.
When documentation is unclear, care teams may repeat painful conversations, families may receive conflicting information, clinicians may struggle to determine the patient’s wishes, and patients may receive care that does not align with their goals.
Why This Topic Matters
For CDI and coding professionals, the role is not to query for advance care planning the same way we query for a diagnosis. This is not about chasing a code or forcing a templated phrase. Instead, CDI and coding leaders can help organizations understand where documentation gaps create risk.
For example, does code status documentation align with the goals-of-care note? Is Z66 being assigned appropriately when the record supports DNR status? Are advance directives scanned but not referenced in the clinical documentation? Are POLST or similar portable medical orders visible across care settings? Are palliative care notes structured in a way that supports both clinical continuity and quality measure capture? Are providers documenting the actual conversation, or only the outcome? This is the kind of work that requires collaboration across disciplines.
Quality teams may own measure reporting. Informatics teams may own EHR build and data mapping. Providers own the clinical conversation and documentation. Case management and social work may help identify documents, surrogates, and family contacts. HIM may manage scanned documents and record integrity.
Coding may identify when code assignment is supported. CDI can help connect the clinical story to documentation standards and organizational education. No single department can own this alone.
Hospitals should begin by reviewing where advance care planning information currently lives in the record. Is it in discrete fields? Scanned documents? Provider notes? Nursing admission questions? Palliative care consults? Case management notes? Problem lists? Orders? Code status fields? Discharge planning documentation?
Do These Sources Agree with Each Other?
If the advance directive says one thing, the code status order says another, and the progress note says something vague, the record is not telling a reliable story. If a patient’s preferences are documented once but never revisited after a major change in condition, the record may not reflect the current clinical reality. If a surrogate is identified in one location but not visible elsewhere, the information may not be useful when it is urgently needed. This is where strong documentation practice matters.
CMS states that advance care planning documentation should include the voluntary nature of the discussion, an explanation of advance directives, who was present, and the time spent discussing advance care planning during the face-to-face encounter. CMS also notes that if the service is billed more than once, the medical record should document a change in the patient’s health status, wishes about end-of-life care, or both. [2]
That does not mean every advance care planning note should become longer or more burdensome. The goal is not longer documentation. The goal is clearer documentation.
A clear advance care planning note should identify the participants, summarize the patient’s goals and preferences, clarify the decision-maker or surrogate structure, reference any reviewed documents, document decisions or changes made during the encounter, and connect the plan of care to the patient’s stated wishes.
As CMS continues to move quality measurement toward electronic data capture, hospitals need to understand that documentation integrity is no longer limited to diagnoses, DRGs, mortality models, complications, or denials. It also includes the integrity of patient preference data.
The eCQI Resource Center notes that eCQMs use clinical data electronically extracted from health information technology systems and are used to evaluate care systems, support quality improvement, and report to CMS, The Joint Commission, other federal agencies, and commercial payers through programs that may monitor, benchmark, or determine reimbursement based on quality of care. [4]
Advance Care Planning: The Patient’s Voice in the Medical Record
If that voice is documented only as a checkbox, it may not be heard. If it is buried in a note that no one can find, it may not be used. If it is not mapped correctly, it may not be counted. And if it is unclear, the next care team may not know how to honor it.
The proposed Advance Care Planning eCQM should be viewed as more than another measure. It is a reminder that the medical record must preserve the patient’s goals, not just the hospital’s data. Remember the following:
- The conversation is human.
- The documentation is clinical.
- The data is measurable.
- And the integrity of all three matters.
References
[1] Centers for Medicare & Medicaid Services. FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule — CMS-1849-P. CMS Newsroom, April 10, 2026.
Link: https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-ipps-long-term-care-hospital-prospective
[2] Centers for Medicare & Medicaid Services. MLN909289 – Advance Care Planning. Medicare Learning Network, March 2026.
Link: https://www.cms.gov/files/document/mln-advanced-care-planning.pdf
[3] eCQI Resource Center. Advance Care Planning, CMS1317v1, Hospital Inpatient eCQM.
Link: https://ecqi.healthit.gov/ecqm/hosp-inpt/2028/cms1317v1
[4] eCQI Resource Center. Get Started with eCQMs – About eCQMs. Updated March 9, 2026.
Link: https://ecqi.healthit.gov/ecqms/about-ecqms
