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-00040

Nadia Larkspur: Heart failure

ENC-00040 · 83F · Cardiology · admitted Thu Nov 05, 2026 09:07 PM · discharged Sun Nov 08, 2026 04:09 PM · attending Dr. Isaac Abernath · resident Dr. Priya Thorne

Clinical judgement required Clinical judgement required Open

Clinical judgement required: Only one acute indicator; acuity needs clinical judgement.

Documented vs supported

Documented: “CHF” · 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: principal → —
MS-DRG (illustrative): 292 Heart failure and shock with CC → 292 Heart failure and shock with CC
Relative weight: 0.8490 → 0.8490 (+0.0000)
Codes before: I50.9, E44.0, N28.9, E11.9, I10, K21.9
Codes after: I50.9, E44.0, N28.9, E11.9, I10, K21.9

All open gaps on this encounter together: MS-DRG 292 → 292 (RW +0.0000). The grouping does not change; the record becomes accurate.

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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Latest LVEF within 12 months (%)	63.0	echo LVEF 63% · echo ECH-000018 · 2026-11-07 01:07
IV loop diuretic given this stay	True	furosemide 40 mg IV · med MED-000147 · 2026-11-06 00:07
Highest BNP this stay (pg/mL)	54.0	BNP 54 pg/mL · lab LAB-001375 · 2026-11-05 22:07

Rule trace (inputs, thresholds, outcome)

Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=54.0, 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=63.0, t.pres=50, t.ref=40	diastolic
derived: improved	`coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false)`	lvef=63.0, 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=False	unknown
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	acuity=unknown, hf_type=diastolic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	acuity=unknown, hf_type=diastolic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	acuity=unknown, hf_type=diastolic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	acuity=unknown, hf_type=diastolic	unknown
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	acuity=unknown, hf_type=diastolic	unknown
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	acuity=unknown, hf_type=diastolic	unknown
outcome: one_indicator	`acute_count == 1`	acute_count=1	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2033); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: cardiac documentation
Encounter: ENC-00040   Patient: Nadia Larkspur   To: Dr. Isaac Abernath

Clinical indicators from the health record:
- Documented in the record: "CHF" [History and physical DOC-000134]
- echo LVEF 63% (2026-11-07 01:07) [echo ECH-000018]
- furosemide 40 mg IV (2026-11-06 00:07) [med MED-000147]
- BNP 54 pg/mL (2026-11-05 22:07) [lab LAB-001375]

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 Documented “acute renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 1) (N17.9).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2033	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00040, ENC-00040.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 3a626946a619
1207	2026-11-14T19:24:28	system:llm system	`llm.call`	ENC-00040, ENC-00040.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 738dd6dfd140
465	2026-11-14T18:29:03	system:llm system	`llm.call`	ENC-00040, ENC-00040.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 67a1112ee69b