Is your hospital ready for hybrid measures? Many clinical documentation integrity (CDI) departments have incorporated Centers for Medicare & Medicaid Services (CMS) quality measures into their repertoire of skills. This shift made perfect sense, as quality measures have transitioned from primarily abstracted data to administrative and claims data, which is based on provider documentation.
However, another shift in quality measure reporting is underway with the implementation of hybrid measures. The Hospital Inpatient Quality Program (IQR) includes two hybrid measures that impact the fiscal year (FY) 2026 payment determination (data collected from July 2023 through June 30, 2024):
- The Hybrid Hospital-Wide All-Cause Readmission Measure (HWR); and
- The Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (HWM), using discharge data.
A hybrid measure incorporates both data pulled from the electronic medical record (EMR), referred to as core clinical data elements (CCDEs), and claims data. CCDEs include laboratory tests and vital signs pulled directly from the EMR. This data will be used to improve case mix risk adjustment, in conjunction with condition categories that are part of the Hierarchical Condition Categories (HCCs) methodology for risk-standardized rates.
Although data collection already occurred for FY 2026, hospitals need to be aware of this new methodology, because its use will likely be expanded. Furthermore, quality measures are often trialed in the IQR program before becoming incorporated into other CMS programs, like Hospital Value Based Purchasing (HVBP), as recently occurred with the Severe Sepsis and Septic Shock Early Management Bundle that was first introduced in the IQR program in 2015.
Unlike the current mortality measures in HVBP and the readmission measures in the Hospital Readmission Reduction Program (HRRP), these measures are not limited to populations admitted for a few diagnoses or procedures (e.g., acute myocardial infarction, heart failure, pneumonia, etc.). These measures are all-cause.
Therefore, a death or readmission from any cause within 30 days of an indexed admission may be included in the measure population. Just like with HRRP, a hospital cannot add a discharge disposition code or other documentation to designate a planned readmission to exclude a claim from the measure; planned readmissions are determined by an algorithm.
Inclusion and Exclusion Criteria
These measures include many of the same criteria as current HVBP mortality measures and HRRP readmission measures that limit inclusion to the Medicare Fee-for-Service (FFS) population at short-term acute-care hospitals, also known as subsection (d) hospitals. However, since these are all-cause measures, they also include other criteria. Neither measure includes patients:
- Discharged against medical advice (AMA);
- Admitted for primary psychiatric diagnoses; and
- Admitted for rehabilitation.
Inclusion criteria for HWM are:
- Enrolled in Medicare FFS Part A for at least 12 months prior to the date of admission and during the index admission;
- Not transferred from another acute-care facility;
- Aged between 65 and 94 years;
- Not enrolled in hospice at the time of, or 12 months prior to their index admission, or within two days of admission;
- Not with a principal diagnosis of cancer and enrolled in hospice during their index admission;
- Without any diagnosis of metastatic cancer; and
- Not with a principal discharge diagnosis, or a secondary diagnosis that is present on admission (POA) for a condition for which hospitals have limited ability to influence survival.
The HWM measure excludes indexed admissions for patients:
- With inconsistent or unknown vital status;
- With an admission for crush injury (Clinical Classification Software – CCS 234), burn (CCS 240), intracranial injury (CCS 233), spinal cord injury (CCS 227), skull and face fractures (CCS 228), or open wounds of head, neck, and trunk (CCS 235); or
- With an admission in a low-volume CCS group.
Inclusion criteria for HWR are the following:
- Enrolled in Medicare Fee-For-Service (FFS) Part A for the 12 months prior to the date of the index admission and during the index admission;
- Aged 65 or over;
- Discharged alive from a non-federal short-term acute-care hospital or Veterans Affairs (VA) hospital;
- Not transferred to another acute-care facility; and
- Patients who have an unplanned readmission and expired within 30 days of discharge from the indexed admission will be included, as long as they meet criteria.
The HWR measure excludes indexed admissions for patients:
- Without at least 30 days of post-discharge enrollment in Medicare FFS (not applicable to VA hospitalizations);
- With a principal diagnosis code of COVID-19 or with a secondary diagnosis code of COVID-19 coded as present on admission (POA) on the index admission claim;
- Admitted for medical treatment of cancer; and
- With fewer than the following minimum laboratory test/vital signs CCDE reported, as defined by the specialty cohort:
- Cardiorespiratory — 5 CCDE;
- Cardiovascular — 5 CCDE;
- Medicine — 6 CCDE;
- Neurology — 5 CCDE; and
- Surgery/Gynecology — 2 vital signs CCD.
Core Clinical Data Elements
Abstraction of core clinical data elements is automated through the EMR. These elements are designed to reflect the patient’s clinical status upon arrival at the hospital. In general, vital signs are collected within two hours (120 minutes) after the start of the inpatient admission, and laboratory tests within 24 hours (1,440 minutes) after the start of the inpatient admission. However, if the patient has values captured prior to admission, the logic supports extraction within 24 hours (1440 minutes) prior to the start of the inpatient admission.
Both the hybrid mortality and readmissions include the CCDE risk variables of the following:
- Bicarbonate;
- Creatinine;
- Heart rate;
- Hematocrit;
- Oxygen saturation (by pulse oximetry);
- Sodium;
- Systolic blood pressure;
- Temperature; and
- White blood cell (WBC) count.
The readmission measure also includes:
- Glucose;
- Potassium;
- Respiratory rate; and
- Weight.
And the mortality measure also includes platelet count.
The Financial Impact of Poor Performance
Low performance on these hybrid measures is unlikely to result in a penalty under IQR, but if it does, the penalty is much lower than what occurs with HVBP and HRRP.
- Hospitals that satisfactorily met the requirements for the Hospital IQR Program receive the full annual market basket update.
- Both hospitals that did not satisfactorily meet the criteria for the Hospital IQR or hospitals that chose not to participate receive their annual market basket update, with a reduction by one-fourth of the applicable market basket update.
The CMS annual market basket update payment refers to the adjustments made to Medicare payments based on cost-of-living increases. The increase in Inpatient Prospective Payment System (IPPS) operating payment rates for general acute-care hospitals that successfully participate in the IQR program and are meaningful electronic health record users under the Medicare Promoting Interoperability Program is 2.6 percent for FY 2026.
Hospitals may turn to CDI professionals if their performance is below expectations or leads to a penalty. To learn more information about these measures, visit the Hybrid Hospital-Wide Readmission (HWR) and Hospital-Wide Mortality (HWM) Measures pages at the CMS.gov Hybrid Measures Overview.
