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-00080
Priya Nakashima: Acute respiratory failure
ENC-00080 · 85F · Cardiology · admitted Sun Nov 08, 2026 08:57 PM · in hospital · attending Dr. Wes Merriweather · resident Dr. Elena Nakashima
Clinical validation gap Criteria not met Open
In hospital: concurrent review Resident note awaiting attending cosign
Documented “acute respiratory failure with hypoxia” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 93%), oxygen no more than 2 L/min, no advanced support.
Documented vs supported
- Documented
- “acute respiratory failure with hypoxia” · J96.01 Acute respiratory failure with hypoxia
- Criteria support
- criteria not met
- Outcome
- No hypoxaemia on room air (lowest SpO2 93%), oxygen no more than 2 L/min, no advanced support
- Rule
- Acute hypoxic respiratory failure v2026.11-1
- Published source
- Merck Manual Professional Version: Acute Hypoxemic Respiratory Failure (AHRF), including ARDS (2026), Definition/evaluation: PaO2 <60 mmHg, PaO2/FiO2 <300, or SpO2 <88%, with dyspnea and tachypnea · source (checked 2026-11-14)
- Contested
- Organizations use different oxygen-saturation cut-offs (SpO2 <88%, <=90% or <91% on room air). This rule uses <88% (the source above) and a LOCAL respiratory-rate cut-off of 28/min as one sign of respiratory distress.
Effect if the clinician agrees (illustrative)
- Change
- remove J96.01
- Secondary-diagnosis level
- MCC → removed
- MS-DRG (illustrative)
- 291 Heart failure and shock with MCC → 292 Heart failure and shock with CC
- Relative weight
- 1.2838 → 0.8490 (-0.4348)
- Codes before
- I50.22, E66.01, J96.01, D62, I10, K21.9, E11.9
- Codes after
- I50.22, E66.01, D62, I10, K21.9, E11.9
All open gaps on this encounter together: MS-DRG 291 → 292 (RW -0.4348).
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 |
|---|---|---|
| Lowest SpO2 on room air (%) | 93.0 |
SpO2 93% on room air
|
| Highest respiratory rate (/min) | 21.0 |
respiratory rate 21/min
|
| Highest supplemental oxygen flow (L/min) | 2.0 |
O2 2 L/min (nasal cannula)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: measured | present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min) |
pao2_min_ra=unknown, pf_min=unknown, spo2_min_ra=93.0 | true |
| derived: hypoxemia | coalesce(spo2_min_ra < t.spo2_ra, false) or coalesce(pao2_min_ra < t.pao2, false) or coalesce(pf_min < t.pf, false) |
pao2_min_ra=unknown, pf_min=unknown, spo2_min_ra=93.0, t.pao2=60, t.pf=300, t.spo2_ra=88 | false |
| derived: distress | coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support |
adv_resp_support=False, rr_max=21.0, t.rr_distress=28, wob_increased=unknown | false |
| outcome: chronic_baseline | home_o2 and hypoxemia |
home_o2=False, hypoxemia=False | false |
| outcome: met | hypoxemia and distress |
distress=False, hypoxemia=False | false |
| outcome: hypoxemia_only | hypoxemia |
hypoxemia=False | false |
| outcome: not_met | measured and not hypoxemia and o2_max_lpm <= t.o2_low and not adv_resp_support |
adv_resp_support=False, hypoxemia=False, measured=True, o2_max_lpm=2.0, t.o2_low=2 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2126); clinical indicators and answer options assembled by code from the rule and the record.
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DOCUMENTATION QUERY (draft) Title: Clarification request: respiratory documentation Encounter: ENC-00080 Patient: Priya Nakashima To: Dr. Wes Merriweather Clinical indicators from the health record: - Documented in the record: "acute respiratory failure with hypoxia" [Progress note DOC-000276] - SpO2 93% on room air (2026-11-11 05:17) [vital VIT-007849] - respiratory rate 21/min (2026-11-09 13:17) [vital VIT-007839] - O2 2 L/min (nasal cannula) (2026-11-09 05:22) [vital VIT-007837] Question: The indicators above are documented in this encounter. Could you clarify the status of the documented respiratory diagnosis? Response options (select one or write your own): ( ) Acute respiratory failure with hypoxia: confirmed (please document the supporting clinical information) ( ) Acute respiratory failure with hypoxia: ruled out ( ) 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
- Chronic kidney disease · Specificity gap Criteria support Chronic kidney disease stage 3a (N18.31); no corresponding diagnosis is documented.
- Heart failure · Specificity gap Documented “chronic systolic heart failure” (I50.22); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).
- Obesity · Clinical validation gap Documented “morbid obesity” (E66.01) conflicts with what the criteria support (Obesity, class 1, E66.811).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2126 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00080, ENC-00080.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 4b440c31629c output 1d1d513022f3 entry 9049c3450b10 |
| 1300 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00080, ENC-00080.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 4b440c31629c output 1d1d513022f3 entry b721739a52fe |
| 558 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00080, ENC-00080.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 4b440c31629c output 1d1d513022f3 entry 4c1e84728a05 |