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-00097

Ines Ashgrove: Heart failure

ENC-00097 · 79F · Cardiology · admitted Sun Nov 01, 2026 10:21 AM · discharged Thu Nov 05, 2026 02:15 PM · attending Dr. Cyrus Ellingham · resident Dr. Camila Oyelaran

Specificity gap Criteria met Open

Documented “congestive heart failure” (I50.9); criteria support the more specific Chronic systolic (HFrEF) heart failure (I50.22).

Documented vs supported

Documented: “congestive heart failure” · I50.9 Heart failure, unspecified
Criteria support: Chronic systolic (HFrEF) heart failure · I50.22 Chronic systolic (congestive) heart failure
Outcome: LVEF 26%, prior heart failure, no acute indicators
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: principal I50.9 -> I50.22
Secondary-diagnosis level: principal → principal
MS-DRG (illustrative): 291 Heart failure and shock with MCC → 291 Heart failure and shock with MCC
Relative weight: 1.2838 → 1.2838 (+0.0000)
Codes before: I50.9, E43, N18.31
Codes after: I50.22, E43, N18.31

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

0.0 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 (%)	26.0	echo LVEF 26% · echo ECH-000046 · 2026-05-21 10:21
Highest BNP this stay (pg/mL)	65.0	BNP 65 pg/mL · lab LAB-003297 · 2026-11-01 11:21
Prior heart failure on the problem list / history	True	history: heart failure with reduced ejection fraction · history HX-000036

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=65.0, ntprobnp_max=unknown, t.bnp=100, t.ntprobnp=300	false
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=False, new_o2=False, np_elevated=False	0
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=26.0, 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=26.0, 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=0, hf_history=True	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=chronic, hf_type=systolic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	acuity=chronic, hf_type=systolic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	acuity=chronic, hf_type=systolic	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2156); clinical indicators and answer options assembled by code from the rule and the record.

Sign in to act. Sign in as a demo user (a CDI specialist sends queries).

DOCUMENTATION QUERY (draft)
Title: Clarification request: cardiac documentation
Encounter: ENC-00097   Patient: Ines Ashgrove   To: Dr. Cyrus Ellingham

Clinical indicators from the health record:
- Documented in the record: "congestive heart failure" [History and physical DOC-000328]
- echo LVEF 26% (2026-05-21 10:21) [echo ECH-000046]
- BNP 65 pg/mL (2026-11-01 11:21) [lab LAB-003297]
- history: heart failure with reduced ejection fraction [history HX-000036]

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):
( ) Chronic 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

Chronic kidney disease · Clinical judgement required Clinical judgement required: Pre-admission eGFR values fall on both sides of 60.
Malnutrition · Clinical validation gap Documented “severe protein-calorie malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2156	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00097, ENC-00097.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry cf3cf58781f7
1330	2026-11-14T19:24:30	system:llm system	`llm.call`	ENC-00097, ENC-00097.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 783a59c1f4b4
588	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00097, ENC-00097.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 1720a8d8cde8