Extended criteria (experimental).
This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects
for CDI staff. The primary surface is Before you sign (kidney, measurement only).
All extended pages.
← Back to the worklist · Whole encounter ENC-00006
Wes Upfield: Acute respiratory failure
ENC-00006 · 72F · Pulmonology · admitted Mon Nov 02, 2026 09:10 PM · discharged Tue Nov 10, 2026 11:39 AM · attending Dr. Isaac Abernath · resident Dr. Priya Thorne
Specificity gap Criteria met Open
Criteria support Acute respiratory failure with hypoxia (J96.01); no corresponding diagnosis is documented.
Documented vs supported
- Documented
- not documented
- Criteria support
- Acute respiratory failure with hypoxia · J96.01 Acute respiratory failure with hypoxia
- Outcome
- Hypoxaemia criterion met with a sign of respiratory distress
- Rule
- Acute hypoxic respiratory failure v2026.11-1
- Published source
- Merck Manual Professional Version: Acute Hypoxemic Respiratory Failure (AHRF), including ARDS (2026), Definition/evaluation: PaO2 <60 mmHg, PaO2/FiO2 <300, or SpO2 <88%, with dyspnea and tachypnea · source (checked 2026-11-14)
- Contested
- Organizations use different oxygen-saturation cut-offs (SpO2 <88%, <=90% or <91% on room air). This rule uses <88% (the source above) and a LOCAL respiratory-rate cut-off of 28/min as one sign of respiratory distress.
Effect if the clinician agrees (illustrative)
- Change
- add J96.01
- Secondary-diagnosis level
- — → MCC
- MS-DRG (illustrative)
- 191 Chronic obstructive pulmonary disease with CC → 190 Chronic obstructive pulmonary disease with MCC
- Relative weight
- 0.8430 → 1.1077 (+0.2647)
- Codes before
- J44.1, E66.9, N17.9, I10, E78.5, K21.9
- Codes after
- J44.1, E66.9, N17.9, I10, E78.5, K21.9, J96.01
All open gaps on this encounter together: MS-DRG 191 → 190 (RW +0.2647).
CC/MCC status, CC exclusions (subset) and relative weights from the public CMS FY2026 IPPS final rule tables (5, 6I, 6J, 6K). This is not a grouper and not a payment estimate. Queries never mention any of this.
Severity documentation index change SIMULATED
1.0 points
SIMULATED: Illustrative severity weights (MCC = 1.0, CC = 0.5, non-CC = 0) summed over secondary diagnoses; not a validated risk-adjustment model and not a measured effect.
Evidence
Structured values are read by code from the cited rows. Note facts are shown only when the model's quote was found verbatim in the note.
| Input | Value | Source |
|---|---|---|
| Lowest SpO2 on room air (%) | 86.0 |
SpO2 86% on room air
|
| Lowest PaO2 on room air (mmHg) | 53.0 |
PaO2 53 mmHg on room air
|
| Lowest PaO2/FiO2 ratio PaO2 / FiO2 (room air FiO2 0.21 when none recorded) |
252 |
PaO2 53 mmHg
FiO2 21
|
| Highest respiratory rate (/min) | 31.0 |
respiratory rate 31/min
|
| Highest supplemental oxygen flow (L/min) | 5.0 |
O2 5 L/min (nasal cannula)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: measured | present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min) |
pao2_min_ra=53.0, pf_min=252, spo2_min_ra=86.0 | true |
| derived: hypoxemia | coalesce(spo2_min_ra < t.spo2_ra, false) or coalesce(pao2_min_ra < t.pao2, false) or coalesce(pf_min < t.pf, false) |
pao2_min_ra=53.0, pf_min=252, spo2_min_ra=86.0, t.pao2=60, t.pf=300, t.spo2_ra=88 | true |
| derived: distress | coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support |
adv_resp_support=False, rr_max=31.0, t.rr_distress=28, wob_increased=unknown | true |
| outcome: chronic_baseline | home_o2 and hypoxemia |
home_o2=False, hypoxemia=True | false |
| outcome: met | hypoxemia and distress |
distress=True, hypoxemia=True | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #1972); clinical indicators and answer options assembled by code from the rule and the record.
Sign in to act. Sign in as a demo user (a CDI specialist sends queries).
DOCUMENTATION QUERY (draft) Title: Clarification request: respiratory documentation Encounter: ENC-00006 Patient: Wes Upfield To: Dr. Isaac Abernath Clinical indicators from the health record: - SpO2 86% on room air (2026-11-02 21:30) [vital VIT-000491] - PaO2 53 mmHg on room air (2026-11-02 21:35) [lab LAB-000186] - FiO2 21 (2026-11-02 21:35) [lab LAB-000187] - respiratory rate 31/min (2026-11-02 21:30) [vital VIT-000492] - O2 5 L/min (nasal cannula) (2026-11-02 21:40) [vital VIT-000493] Question: Based on your clinical judgement and the indicators above, can the respiratory diagnosis being evaluated and treated be further specified? Response options (select one or write your own): ( ) Acute respiratory failure with hypoxia ( ) Hypoxemia without respiratory failure ( ) Other (please specify): ____________ ( ) Unable to determine Please respond based on your independent clinical judgement. Any response, including "unable to determine", is acceptable. This query and your response are kept as part of the health record.
Other findings on this encounter
- Obesity · Specificity gap Documented “obesity” (E66.9); criteria support the more specific Obesity, class 1 (E66.811).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 1972 | 2026-11-14T20:57:22 | system:llm system |
llm.call |
ENC-00006, ENC-00006.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 2010a5d3d887 |
| 1146 | 2026-11-14T19:24:27 | system:llm system |
llm.call |
ENC-00006, ENC-00006.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 1edf5e52a5f6 |
| 404 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00006, ENC-00006.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 92cbf631fa1f |