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-00041
Ines Nakashima: Heart failure
ENC-00041 · 79M · Hospital Medicine · admitted Sat Oct 31, 2026 12:31 PM · discharged Thu Nov 05, 2026 10:28 AM · attending Dr. Wes Merriweather · resident Dr. Noor Halvorsen
Clinical judgement required Clinical judgement required Open
Clinical judgement required: Only one acute indicator; acuity needs clinical judgement.
Documented vs supported
- Documented
- “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)
- 193 Simple pneumonia and pleurisy with MCC → 193 Simple pneumonia and pleurisy with MCC
- Relative weight
- 1.3144 → 1.3144 (+0.0000)
- Codes before
- J18.9, E43, I50.9
- Codes after
- J18.9, E43, I50.9
All open gaps on this encounter together: MS-DRG 193 → 194 (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 (%) | 32.0 |
echo LVEF 32%
|
| IV loop diuretic given this stay | True |
furosemide 40 mg IV
|
| Highest BNP this stay (pg/mL) | 51.0 |
BNP 51 pg/mL
|
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=51.0, 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=32.0, 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=32.0, 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=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 #2034); 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-00041 Patient: Ines Nakashima To: Dr. Wes Merriweather Clinical indicators from the health record: - Documented in the record: "heart failure" [Progress note DOC-000139] - echo LVEF 32% (2026-11-01 02:31) [echo ECH-000019] - furosemide 40 mg IV (2026-10-31 15:31) [med MED-000151] - BNP 51 pg/mL (2026-10-31 13:31) [lab LAB-001401] 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
- Hyponatraemia · Specificity gap Criteria support Hyponatraemia (moderate) (E87.1); no corresponding diagnosis is documented.
- Malnutrition · Clinical validation gap Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2034 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00041, ENC-00041.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 56f955262c5b |
| 1208 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00041, ENC-00041.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 9d300b746849 |
| 466 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00041, ENC-00041.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 036a84260a1a |