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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Camila Upfield: Heart failure

ENC-00085 · 76M · Hospital Medicine · admitted Sat Oct 31, 2026 07:25 PM · discharged Tue Nov 03, 2026 10:16 AM · attending Dr. Wes Merriweather · resident Dr. Noor Halvorsen

Specificity gap Criteria met Open

Documented “HFrEF” (I50.20); criteria support the more specific Acute systolic (HFrEF) heart failure (I50.21).

Documented vs supported

Documented: “HFrEF” · I50.20 Unspecified systolic (congestive) heart failure
Criteria support: Acute systolic (HFrEF) heart failure · I50.21 Acute systolic (congestive) heart failure
Outcome: LVEF 29% with 3 acute indicators, no prior heart failure on file
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: I50.20 -> I50.21
Secondary-diagnosis level: CC → MCC
MS-DRG (illustrative): 871 Septicemia or severe sepsis without MV >96 hours with MCC → 871 Septicemia or severe sepsis without MV >96 hours with MCC
Relative weight: 1.9425 → 1.9425 (+0.0000)
Codes before: A41.9, N39.0, I50.20, J96.01, L89.154, I10
Codes after: A41.9, N39.0, J96.01, L89.154, I10, I50.21

All open gaps on this encounter together: MS-DRG 871 → 871 (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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Latest LVEF within 12 months (%)	29.0	echo LVEF 29% · echo ECH-000039 · 2026-11-02 01:25
IV loop diuretic given this stay	True	furosemide 40 mg IV · med MED-000325 · 2026-10-31 20:00 furosemide 40 mg IV · med MED-000326 · 2026-11-01 08:00 furosemide 40 mg IV · med MED-000327 · 2026-11-01 20:00 furosemide 40 mg IV · med MED-000328 · 2026-11-02 08:00
Highest BNP this stay (pg/mL)	1013.0	BNP 1013 pg/mL · lab LAB-002870 · 2026-10-31 20:25
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-008267 · 2026-11-01 03:50

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=1013.0, 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=29.0, 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=29.0, 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=False	acute
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, hf_type=systolic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	acuity=acute, hf_type=systolic	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2133); 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-00085   Patient: Camila Upfield   To: Dr. Wes Merriweather

Clinical indicators from the health record:
- Documented in the record: "HFrEF" [Progress note DOC-000291]
- echo LVEF 29% (2026-11-02 01:25) [echo ECH-000039]
- furosemide 40 mg IV (2026-10-31 20:00) [med MED-000325]
- furosemide 40 mg IV (2026-11-01 08:00) [med MED-000326]
- furosemide 40 mg IV (2026-11-01 20:00) [med MED-000327]
- furosemide 40 mg IV (2026-11-02 08:00) [med MED-000328]
- BNP 1013 pg/mL (2026-10-31 20:25) [lab LAB-002870]
- O2 2 L/min (nasal cannula) (2026-11-01 03:50) [vital VIT-008267]

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 systolic heart failure (HFrEF)
( ) Acute on 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 validation gap Documented “acute hypoxic respiratory failure” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 94%), oxygen no more than 2 L/min, no advanced support.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2133	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00085, ENC-00085.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 2ce94e71f77c
1307	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00085, ENC-00085.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 53d94c1c0965
565	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00085, ENC-00085.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry f7ee8fd7476d