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-00025

Nico Elsworth: Acute respiratory failure

ENC-00025 · 83M · Cardiology · admitted Sat Nov 07, 2026 06:36 PM · discharged Tue Nov 10, 2026 04:36 PM · attending Dr. Rosalind Quillan

Specificity gap Criteria met Open

Documented “hypoxia” (R09.02); criteria support the more specific Acute respiratory failure with hypoxia (J96.01).

Documented vs supported

Documented: “hypoxia” · R09.02 Hypoxemia
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: R09.02 -> J96.01
Secondary-diagnosis level: non-CC → MCC
MS-DRG (illustrative): 292 Heart failure and shock with CC → 291 Heart failure and shock with MCC
Relative weight: 0.8490 → 1.2838 (+0.4348)
Codes before: I50.9, N17.9, R09.02, I10, E78.5, K21.9
Codes after: I50.9, N17.9, I10, E78.5, K21.9, J96.01

All open gaps on this encounter together: MS-DRG 292 → 291 (RW +0.4348).

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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Lowest SpO2 on room air (%)	86.0	SpO2 86% on room air · vital VIT-002457 · 2026-11-07 18:56
Lowest PaO2 on room air (mmHg)	55.0	PaO2 55 mmHg on room air · lab LAB-000854 · 2026-11-07 19:01
Lowest PaO2/FiO2 ratio PaO2 / FiO2 (room air FiO2 0.21 when none recorded)	262	PaO2 55 mmHg · lab LAB-000854 · 2026-11-07 19:01 FiO2 21 · lab LAB-000855 · 2026-11-07 19:01
Highest respiratory rate (/min)	28.0	respiratory rate 28/min · vital VIT-002458 · 2026-11-07 18:56
Highest supplemental oxygen flow (L/min)	5.0	O2 5 L/min (nasal cannula) · vital VIT-002459 · 2026-11-07 19:06
Increased work of breathing quoted from a note	True	“increased work of breathing” · History and physical DOC-000081, p. 1, line 8 · quoted span verified Show the quote in the note … . Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia, GERD. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Congestive heart failure: diuresis and daily weights; monitor electrolytes.

Rule trace (inputs, thresholds, outcome)

Rule trace (rule respiratory_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=55.0, pf_min=262, 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=55.0, pf_min=262, 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=28.0, t.rr_distress=28, wob_increased=True	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 #2002); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: respiratory documentation
Encounter: ENC-00025   Patient: Nico Elsworth   To: Dr. Rosalind Quillan

Clinical indicators from the health record:
- Documented in the record: "hypoxia" [Progress note DOC-000082]
- SpO2 86% on room air (2026-11-07 18:56) [vital VIT-002457]
- PaO2 55 mmHg on room air (2026-11-07 19:01) [lab LAB-000854]
- FiO2 21 (2026-11-07 19:01) [lab LAB-000855]
- respiratory rate 28/min (2026-11-07 18:56) [vital VIT-002458]
- O2 5 L/min (nasal cannula) (2026-11-07 19:06) [vital VIT-002459]
- "increased work of breathing" (2026-11-07 21:36) [History and physical DOC-000081, p. 1, line 8]

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

Heart failure · Specificity gap Documented “congestive heart failure” (I50.9); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2002	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00025, ENC-00025.respiratory_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 858549eede6d
1176	2026-11-14T19:24:28	system:llm system	`llm.call`	ENC-00025, ENC-00025.respiratory_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry c16d9ee32a61
434	2026-11-14T18:29:03	system:llm system	`llm.call`	ENC-00025, ENC-00025.respiratory_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry ec7c645fa2bd