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-00101
Celeste Marlow: Acute respiratory failure
ENC-00101 · 63F · Hospital Medicine · admitted Wed Nov 11, 2026 08:39 AM · in hospital · attending Dr. Cyrus Ellingham
Specificity gap Criteria met Open
In hospital: concurrent review
Documented “hypoxia” (R09.02); criteria support the more specific Acute respiratory failure with hypoxia (J96.01).
Documented vs supported
- Documented
- “hypoxia” · R09.02 Hypoxemia
- Criteria support
- Acute respiratory failure with hypoxia · J96.01 Acute respiratory failure with hypoxia
- Outcome
- Hypoxaemia criterion met with a sign of respiratory distress
- 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
- R09.02 -> J96.01
- Secondary-diagnosis level
- non-CC → MCC
- MS-DRG (illustrative)
- 195 Simple pneumonia and pleurisy without CC/MCC → 193 Simple pneumonia and pleurisy with MCC
- Relative weight
- 0.6285 → 1.3144 (+0.6859)
- Codes before
- J18.9, E66.812, N18.30, R09.02, I10, E11.9
- Codes after
- J18.9, E66.812, N18.30, I10, E11.9, J96.01
All open gaps on this encounter together: MS-DRG 195 → 193 (RW +0.6859).
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 (%) | 82.0 |
SpO2 82% on room air
|
| Lowest PaO2 on room air (mmHg) | 52.0 |
PaO2 52 mmHg on room air
|
| Lowest PaO2/FiO2 ratio PaO2 / FiO2 (room air FiO2 0.21 when none recorded) |
248 |
PaO2 52 mmHg
FiO2 21
|
| Highest respiratory rate (/min) | 34.0 |
respiratory rate 34/min
|
| Highest supplemental oxygen flow (L/min) | 5.0 |
O2 5 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=52.0, pf_min=248, spo2_min_ra=82.0 | 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=52.0, pf_min=248, spo2_min_ra=82.0, t.pao2=60, t.pf=300, t.spo2_ra=88 | true |
| derived: distress | coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support |
adv_resp_support=False, rr_max=34.0, t.rr_distress=28, wob_increased=unknown | true |
| outcome: chronic_baseline | home_o2 and hypoxemia |
home_o2=False, hypoxemia=True | false |
| outcome: met | hypoxemia and distress |
distress=True, hypoxemia=True | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2168); 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: respiratory documentation Encounter: ENC-00101 Patient: Celeste Marlow To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "hypoxia" [Progress note DOC-000341] - SpO2 82% on room air (2026-11-11 08:59) [vital VIT-009919] - PaO2 52 mmHg on room air (2026-11-11 09:04) [lab LAB-003455] - FiO2 21 (2026-11-11 09:04) [lab LAB-003456] - respiratory rate 34/min (2026-11-11 08:59) [vital VIT-009920] - O2 5 L/min (nasal cannula) (2026-11-11 09:09) [vital VIT-009921] Question: Based on your clinical judgement and the indicators above, can the respiratory diagnosis being evaluated and treated be further specified? Response options (select one or write your own): ( ) Acute respiratory failure with hypoxia ( ) Hypoxemia without respiratory failure ( ) 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 · Specificity gap Documented “CKD stage 3” (N18.30); criteria support the more specific Chronic kidney disease stage 3b (N18.32).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2168 | 2026-11-14T20:57:25 | system:llm system |
llm.call |
ENC-00101, ENC-00101.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 7f13c765591c |
| 1342 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00101, ENC-00101.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 41e09a7819db |
| 600 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00101, ENC-00101.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt f94cfa3b4fef output 5de8fced5850 entry 089d7273fd79 |