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-00043
Nico Ravensworth: Heart failure
ENC-00043 · 86F · Cardiology · admitted Thu Oct 29, 2026 08:52 AM · discharged Thu Nov 05, 2026 12:42 PM · attending Dr. Jalen Carrow · resident Dr. Greta Kowalczyk
Clinical judgement required Clinical judgement required Open
Clinical judgement required: LVEF 46% (HFmrEF, 41-49%); the type wording and its coding convention need the clinician.
Documented vs supported
- Documented
- “CHF” · I50.9 Heart failure, unspecified
- Criteria support
- no conclusion: clinical judgement required
- Outcome
- LVEF 46% (HFmrEF, 41-49%); the type wording and its coding convention need the clinician
- 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)
- 291 Heart failure and shock with MCC → 291 Heart failure and shock with MCC
- Relative weight
- 1.2838 → 1.2838 (+0.0000)
- Codes before
- I50.9, E46, E87.1, D64.9, L89.154
- Codes after
- I50.9, E46, E87.1, D64.9, L89.154
All open gaps on this encounter together: MS-DRG 291 → 293 (RW -0.7178).
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 (%) | 46.0 |
echo LVEF 46%
|
| IV loop diuretic given this stay | True |
furosemide 40 mg IV
furosemide 40 mg IV
furosemide 40 mg IV
furosemide 40 mg IV
|
| Highest BNP this stay (pg/mL) | 1941.0 |
BNP 1941 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=1941.0, ntprobnp_max=unknown, t.bnp=100, t.ntprobnp=300 | true |
| derived: acute_count | count(iv_loop_diuretic, np_elevated, new_o2) |
iv_loop_diuretic=True, new_o2=False, np_elevated=True | 2 |
| derived: hf_type | case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange') |
lvef=46.0, t.pres=50, t.ref=40 | midrange |
| derived: improved | coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false) |
lvef=46.0, 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=2, hf_history=True | acute on chronic |
| outcome: improved_ef | improved |
improved=False | false |
| outcome: midrange | hf_type == 'midrange' |
hf_type=midrange | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2041); 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-00043 Patient: Nico Ravensworth To: Dr. Jalen Carrow Clinical indicators from the health record: - Documented in the record: "CHF" [History and physical DOC-000147] - echo LVEF 46% (2026-10-29 22:52) [echo ECH-000020] - furosemide 40 mg IV (2026-10-29 20:00) [med MED-000156] - furosemide 40 mg IV (2026-10-30 08:00) [med MED-000157] - furosemide 40 mg IV (2026-10-30 20:00) [med MED-000158] - furosemide 40 mg IV (2026-10-31 08:00) [med MED-000159] - BNP 1941 pg/mL (2026-10-29 09:52) [lab LAB-001465] - history: heart failure with reduced ejection fraction [history HX-000014] 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 · Clinical validation gap Documented “hyponatremia” (E87.1) but the criteria are not met: All sodium values 135 or above (lowest 136).
- Malnutrition · Clinical validation gap Documented “malnourished” (E46) but the criteria are not met: 4 characteristics assessed and none met.
- Pressure injury · Clinical validation gap Documented “stage 4 sacral pressure ulcer” (L89.154) conflicts with what the criteria support (Pressure injury of sacral region, stage 2, L89.152).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2041 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00043, ENC-00043.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 9e83917f317f |
| 1215 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00043, ENC-00043.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 80d9933c27b2 |
| 473 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00043, ENC-00043.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry d057a53c3243 |