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.

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Keira Ravensworth: Heart failure

ENC-00081 · 84F · Pulmonology · admitted Sat Nov 07, 2026 02:15 PM · in hospital · attending Dr. Gideon Zeller · resident Dr. Priya Thorne

Specificity gap Criteria met Open In hospital: concurrent review Resident note awaiting attending cosign

Documented “congestive heart failure” (I50.9); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).

Documented vs supported

Documented: “congestive heart failure” · I50.9 Heart failure, unspecified
Criteria support: Acute on chronic systolic (HFrEF) heart failure · I50.23 Acute on chronic systolic (congestive) heart failure
Outcome: LVEF 32% 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: I50.9 -> I50.23
Secondary-diagnosis level: non-CC → MCC
MS-DRG (illustrative): 191 Chronic obstructive pulmonary disease with CC → 190 Chronic obstructive pulmonary disease with MCC
Relative weight: 0.8430 → 1.1077 (+0.2647)
Codes before: J44.1, E66.811, N17.9, I50.9, R09.02, D62
Codes after: J44.1, E66.811, N17.9, R09.02, D62, I50.23

All open gaps on this encounter together: MS-DRG 191 → 190 (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

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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Latest LVEF within 12 months (%)	32.0	echo LVEF 32% · echo ECH-000038 · 2026-11-08 08:15
IV loop diuretic given this stay	True	furosemide 40 mg IV · med MED-000310 · 2026-11-07 20:00 furosemide 40 mg IV · med MED-000311 · 2026-11-08 08:00 furosemide 40 mg IV · med MED-000312 · 2026-11-08 20:00 furosemide 40 mg IV · med MED-000313 · 2026-11-09 08:00
Highest BNP this stay (pg/mL)	2035.0	BNP 2035 pg/mL · lab LAB-002752 · 2026-11-07 15:15
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) · vital VIT-007929 · 2026-11-07 22:35
Prior heart failure on the problem list / history	True	history: heart failure with reduced ejection fraction · history HX-000030

Rule trace (inputs, thresholds, outcome)

Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=2035.0, 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=32.0, t.pres=50, t.ref=40	systolic
derived: improved	`coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false)`	lvef=32.0, 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=systolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	acuity=acute on chronic, hf_type=systolic	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2127); 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-00081   Patient: Keira Ravensworth   To: Dr. Gideon Zeller

Clinical indicators from the health record:
- Documented in the record: "congestive heart failure" [Progress note DOC-000278]
- echo LVEF 32% (2026-11-08 08:15) [echo ECH-000038]
- furosemide 40 mg IV (2026-11-07 20:00) [med MED-000310]
- furosemide 40 mg IV (2026-11-08 08:00) [med MED-000311]
- furosemide 40 mg IV (2026-11-08 20:00) [med MED-000312]
- furosemide 40 mg IV (2026-11-09 08:00) [med MED-000313]
- BNP 2035 pg/mL (2026-11-07 15:15) [lab LAB-002752]
- O2 2 L/min (nasal cannula) (2026-11-07 22:35) [vital VIT-007929]
- history: heart failure with reduced ejection fraction [history HX-000030]

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 systolic heart failure (HFrEF)
( ) Chronic systolic heart failure (HFrEF)
( ) 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 respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2127	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00081, ENC-00081.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 0770b7779a54
1301	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00081, ENC-00081.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 666e162bd7a0
559	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00081, ENC-00081.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 091568657d71