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).
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← Back to the worklist · Whole encounter ENC-00053
Amara Merriweather: Heart failure
ENC-00053 · 53M · Pulmonology · admitted Sun Nov 01, 2026 10:14 PM · discharged Wed Nov 04, 2026 01:41 PM · attending Dr. Wes Merriweather
Clinical validation gap Criteria met Open
Documented “acute on chronic diastolic heart failure” (I50.33) is more specific than the criteria support (Chronic diastolic (HFpEF) heart failure, I50.32).
Documented vs supported
- Documented
- “acute on chronic diastolic heart failure” · I50.33 Acute on chronic diastolic (congestive) heart failure
- Criteria support
- Chronic diastolic (HFpEF) heart failure · I50.32 Chronic diastolic (congestive) heart failure
- Outcome
- LVEF 62%, prior heart failure, no acute indicators
- 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.
Effect if the clinician agrees (illustrative)
- Change
- I50.33 -> I50.32
- Secondary-diagnosis level
- MCC → CC
- MS-DRG (illustrative)
- 190 Chronic obstructive pulmonary disease with MCC → 191 Chronic obstructive pulmonary disease with CC
- Relative weight
- 1.1077 → 0.8430 (-0.2647)
- Codes before
- J44.1, N18.9, N28.9, I50.33, D62, E78.5
- Codes after
- J44.1, N18.9, N28.9, D62, E78.5, I50.32
All open gaps on this encounter together: MS-DRG 190 → 191 (RW -0.2647).
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
-0.5 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 (%) | 62.0 |
echo LVEF 62%
|
| Highest BNP this stay (pg/mL) | 58.0 |
BNP 58 pg/mL
|
| Prior heart failure on the problem list / history | True |
history: heart failure with preserved 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=58.0, ntprobnp_max=unknown, t.bnp=100, t.ntprobnp=300 | false |
| derived: acute_count | count(iv_loop_diuretic, np_elevated, new_o2) |
iv_loop_diuretic=False, new_o2=False, np_elevated=False | 0 |
| derived: hf_type | case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange') |
lvef=62.0, 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=62.0, 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=0, hf_history=True | chronic |
| 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=chronic, hf_type=diastolic | false |
| outcome: sys_acute | hf_type == 'systolic' and acuity == 'acute' |
acuity=chronic, hf_type=diastolic | false |
| outcome: sys_chronic | hf_type == 'systolic' and acuity == 'chronic' |
acuity=chronic, hf_type=diastolic | false |
| outcome: dia_aoc | hf_type == 'diastolic' and acuity == 'acute on chronic' |
acuity=chronic, hf_type=diastolic | false |
| outcome: dia_acute | hf_type == 'diastolic' and acuity == 'acute' |
acuity=chronic, hf_type=diastolic | false |
| outcome: dia_chronic | hf_type == 'diastolic' and acuity == 'chronic' |
acuity=chronic, hf_type=diastolic | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2065); 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-00053 Patient: Amara Merriweather To: Dr. Wes Merriweather Clinical indicators from the health record: - Documented in the record: "acute on chronic diastolic heart failure" [Progress note DOC-000186] - echo LVEF 62% (2026-04-15 22:14) [echo ECH-000024] - BNP 58 pg/mL (2026-11-01 23:14) [lab LAB-001807] - history: heart failure with preserved ejection fraction [history HX-000017] Question: The indicators above are documented in this encounter. Could you clarify the type and acuity of the documented heart failure? Response options (select one or write your own): ( ) Acute on chronic diastolic heart failure: confirmed (please document the supporting clinical information) ( ) Chronic diastolic heart failure (HFpEF) ( ) Other explanation of the clinical findings (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).
- Chronic kidney disease · Specificity gap Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 3b (N18.32).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2065 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00053, ENC-00053.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry 0ea609ee746f |
| 1239 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00053, ENC-00053.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry 619967b28172 |
| 497 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00053, ENC-00053.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry fe6aff7686a5 |