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-00065
Lena Upfield: Heart failure
ENC-00065 · 51M · Hospital Medicine · admitted Tue Nov 10, 2026 03:47 PM · in hospital · attending Dr. Rosalind Quillan · resident Dr. Camila Oyelaran
Specificity gap Criteria met Open
In hospital: concurrent review Resident note awaiting attending cosign
Documented “diastolic heart failure” (I50.30); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
Documented vs supported
- Documented
- “diastolic heart failure” · I50.30 Unspecified diastolic (congestive) heart failure
- Criteria support
- Acute on chronic diastolic (HFpEF) heart failure · I50.33 Acute on chronic diastolic (congestive) heart failure
- Outcome
- LVEF 56% with 3 acute indicators and prior heart failure
- 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
- I50.30 -> I50.33
- Secondary-diagnosis level
- CC → MCC
- 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, N18.9, I50.30, R09.02, D64.9
- Codes after
- J18.9, E43, N18.9, R09.02, D64.9, I50.33
All open gaps on this encounter together: MS-DRG 193 → 193 (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
0.5 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 (%) | 56.0 |
echo LVEF 56%
|
| 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) | 1284.0 |
BNP 1284 pg/mL
|
| Supplemental oxygen started this stay without home oxygen supplemental oxygen started this stay without home oxygen on file |
True |
O2 2 L/min (nasal cannula)
|
| 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=1284.0, 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=True, np_elevated=True | 3 |
| derived: hf_type | case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange') |
lvef=56.0, 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=56.0, 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=3, hf_history=True | acute on 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=acute on chronic, hf_type=diastolic | false |
| outcome: sys_acute | hf_type == 'systolic' and acuity == 'acute' |
acuity=acute on chronic, hf_type=diastolic | false |
| outcome: sys_chronic | hf_type == 'systolic' and acuity == 'chronic' |
acuity=acute on chronic, hf_type=diastolic | false |
| outcome: dia_aoc | hf_type == 'diastolic' and acuity == 'acute on chronic' |
acuity=acute on chronic, hf_type=diastolic | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2094); 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-00065 Patient: Lena Upfield To: Dr. Rosalind Quillan Clinical indicators from the health record: - Documented in the record: "diastolic heart failure" [Progress note DOC-000226] - echo LVEF 56% (2026-11-11 13:47) [echo ECH-000031] - furosemide 40 mg IV (2026-11-10 20:00) [med MED-000252] - furosemide 40 mg IV (2026-11-11 08:00) [med MED-000253] - furosemide 40 mg IV (2026-11-11 20:00) [med MED-000254] - furosemide 40 mg IV (2026-11-12 08:00) [med MED-000255] - BNP 1284 pg/mL (2026-11-10 16:47) [lab LAB-002194] - O2 2 L/min (nasal cannula) (2026-11-11 00:07) [vital VIT-006294] - history: heart failure with preserved ejection fraction [history HX-000024] Question: Based on your clinical judgement and the indicators above, can the type and acuity of the heart failure being treated be further specified? Response options (select one or write your own): ( ) Acute on chronic diastolic heart failure (HFpEF) ( ) Chronic diastolic heart failure (HFpEF) ( ) 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 blood loss anaemia · Specificity gap Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).
- Chronic kidney disease · Specificity gap Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
- 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 (chronic illness context), E44.0).
- Acute respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2094 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00065, ENC-00065.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry fe2996cf072e |
| 1268 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00065, ENC-00065.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 21f1185dd257 |
| 526 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00065, ENC-00065.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 350d7c9e0f6c |