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-00037
Amara Yardley: Heart failure
ENC-00037 · 84M · Hospital Medicine · admitted Mon Nov 02, 2026 05:35 PM · discharged Sun Nov 08, 2026 12:51 PM · attending Dr. Cyrus Ellingham · resident Dr. Camila Oyelaran
Clinical judgement required Clinical judgement required Open
Clinical judgement required: Only one acute indicator; acuity needs clinical judgement.
Documented vs supported
- Documented
- “congestive heart failure” · I50.9 Heart failure, unspecified
- Criteria support
- no conclusion: clinical judgement required
- Outcome
- Only one acute indicator; acuity needs clinical judgement
- Rule
- Heart failure type (LVEF) and acuity v2026.11-1
- Published source
- Universal Definition and Classification of Heart Failure (HFSA/HFA/JHFS, 2021), as restated in Chandramouli et al., Clin Cardiol 2022 (2021), LVEF classification: HFrEF <=40%, HFmrEF 41-49%, HFpEF >=50%; HFimpEF = baseline <=40%, rise >=10 points, second LVEF >40% · source (checked 2026-11-14)
- Contested
- No guideline gives a numeric definition of "acute" versus "chronic" heart failure. This rule uses a LOCAL CONVENTION: at least two acute indicators (IV loop diuretic, elevated natriuretic peptide, new oxygen requirement) = acute; with a prior history of heart failure = acute on chronic; none with history = chronic; exactly one = clinical judgement.
Clinical judgement required. The rule does not conclude here. A CDI specialist may send an open query or dismiss the finding; nothing is proposed as fact.
Effect if the clinician agrees (illustrative)
- Change
- no projected change (clinician judgement)
- Secondary-diagnosis level
- non-CC → —
- MS-DRG (illustrative)
- 194 Simple pneumonia and pleurisy with CC → 194 Simple pneumonia and pleurisy with CC
- Relative weight
- 0.8059 → 0.8059 (+0.0000)
- Codes before
- J18.9, E46, I50.9
- Codes after
- J18.9, E46, I50.9
All open gaps on this encounter together: MS-DRG 194 → 193 (RW +0.5085).
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
0.0 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 |
|---|---|---|
| Latest LVEF within 12 months (%) | 30.0 |
echo LVEF 30%
|
| IV loop diuretic given this stay | True |
furosemide 40 mg IV
|
| Highest BNP this stay (pg/mL) | 45.0 |
BNP 45 pg/mL
|
| Prior heart failure on the problem list / history | True |
history: heart failure with reduced ejection fraction
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: np_elevated | coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false) |
bnp_max=45.0, ntprobnp_max=unknown, t.bnp=100, t.ntprobnp=300 | false |
| derived: acute_count | count(iv_loop_diuretic, np_elevated, new_o2) |
iv_loop_diuretic=True, new_o2=False, np_elevated=False | 1 |
| derived: hf_type | case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange') |
lvef=30.0, t.pres=50, t.ref=40 | systolic |
| derived: improved | coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false) |
lvef=30.0, lvef_prior_min=unknown, t.improved_rise=10, t.ref=40 | false |
| derived: acuity | case(acute_count >= 2 and hf_history, 'acute on chronic', acute_count >= 2, 'acute', acute_count == 0 and hf_history, 'chronic', null) |
acute_count=1, hf_history=True | unknown |
| outcome: improved_ef | improved |
improved=False | false |
| outcome: midrange | hf_type == 'midrange' |
hf_type=systolic | false |
| outcome: sys_aoc | hf_type == 'systolic' and acuity == 'acute on chronic' |
acuity=unknown, hf_type=systolic | unknown |
| outcome: sys_acute | hf_type == 'systolic' and acuity == 'acute' |
acuity=unknown, hf_type=systolic | unknown |
| outcome: sys_chronic | hf_type == 'systolic' and acuity == 'chronic' |
acuity=unknown, hf_type=systolic | unknown |
| outcome: dia_aoc | hf_type == 'diastolic' and acuity == 'acute on chronic' |
acuity=unknown, hf_type=systolic | false |
| outcome: dia_acute | hf_type == 'diastolic' and acuity == 'acute' |
acuity=unknown, hf_type=systolic | false |
| outcome: dia_chronic | hf_type == 'diastolic' and acuity == 'chronic' |
acuity=unknown, hf_type=systolic | false |
| outcome: one_indicator | acute_count == 1 |
acute_count=1 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2025); 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: cardiac documentation Encounter: ENC-00037 Patient: Amara Yardley To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "congestive heart failure" [Progress note DOC-000124] - echo LVEF 30% (2026-11-03 12:35) [echo ECH-000015] - furosemide 40 mg IV (2026-11-02 20:35) [med MED-000134] - BNP 45 pg/mL (2026-11-02 18:35) [lab LAB-001261] - history: heart failure with reduced ejection fraction [history HX-000011] Question: Could you review the cardiac indicators above and clarify the type and acuity of the heart failure, if clinically appropriate? Response options (select one or write your own): ( ) 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
- Acute kidney injury · Specificity gap Criteria support Acute kidney injury (KDIGO stage 2) (N17.9); no corresponding diagnosis is documented.
- Malnutrition · Specificity gap Documented “malnutrition” (E46); criteria support the more specific Severe protein-calorie malnutrition (chronic illness context) (E43).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2025 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00037, ENC-00037.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 8f0648f3b9dd |
| 1199 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00037, ENC-00037.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 873610f6667c |
| 457 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00037, ENC-00037.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 7b19d08ee921 |