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← Back to the worklist · Whole encounter ENC-00067
Jun Galloway: Heart failure
ENC-00067 · 73M · Hospital Medicine · admitted Sun Nov 08, 2026 06:57 PM · in hospital · attending Dr. Cyrus Ellingham
Specificity gap Criteria met Open
In hospital: concurrent review
Documented “heart failure” (I50.9); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
Documented vs supported
- Documented
- “heart failure” · I50.9 Heart failure, unspecified
- Criteria support
- Acute on chronic diastolic (HFpEF) heart failure · I50.33 Acute on chronic diastolic (congestive) heart failure
- Outcome
- LVEF 59% with 2 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
- I50.9 -> I50.33
- Secondary-diagnosis level
- non-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, E66.9, N18.32, I50.9, L89.154
- Codes after
- J18.9, E66.9, N18.32, L89.154, 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
1.0 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 (%) | 59.0 |
echo LVEF 59%
|
| 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) | 1086.0 |
BNP 1086 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=1086.0, 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=59.0, 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=59.0, 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=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 #2098); 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-00067 Patient: Jun Galloway To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "heart failure" [Progress note DOC-000232] - echo LVEF 59% (2026-11-09 22:57) [echo ECH-000032] - furosemide 40 mg IV (2026-11-08 20:00) [med MED-000261] - furosemide 40 mg IV (2026-11-09 08:00) [med MED-000262] - furosemide 40 mg IV (2026-11-09 20:00) [med MED-000263] - furosemide 40 mg IV (2026-11-10 08:00) [med MED-000264] - BNP 1086 pg/mL (2026-11-08 19:57) [lab LAB-002268] - history: heart failure with preserved ejection fraction [history HX-000025] 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
- Hyponatraemia · Specificity gap Criteria support Hyponatraemia (profound) (E87.1); no corresponding diagnosis is documented.
- Obesity · Specificity gap Documented “obesity” (E66.9); criteria support the more specific Obesity, class 3 (E66.813).
- 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 |
|---|---|---|---|---|---|---|
| 2098 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00067, ENC-00067.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry e39a7146d0fe |
| 1272 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00067, ENC-00067.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 06ccce2b8e02 |
| 530 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00067, ENC-00067.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry b605d86fbee2 |