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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Dmitri Greaves: Heart failure

ENC-00106 · 83F · Hospital Medicine · admitted Mon Nov 09, 2026 12:02 PM · in hospital · attending Dr. Cyrus Ellingham · resident Dr. Noor Halvorsen

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

Documented “acute on chronic systolic heart failure” (I50.23) is more specific than the criteria support (Chronic systolic (HFrEF) heart failure, I50.22).

Documented vs supported

Documented: “acute on chronic systolic heart failure” · I50.23 Acute on chronic systolic (congestive) heart failure
Criteria support: Chronic systolic (HFrEF) heart failure · I50.22 Chronic systolic (congestive) heart failure
Outcome: LVEF 27%, 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: I50.23 -> I50.22
Secondary-diagnosis level: MCC → CC
MS-DRG (illustrative): 689 Kidney and urinary tract infections with MCC → 690 Kidney and urinary tract infections without MCC
Relative weight: 1.1603 → 0.8095 (-0.3508)
Codes before: N39.0, E46, I50.23, E87.1, I10, E78.5
Codes after: N39.0, E46, E87.1, I10, E78.5, I50.22

All open gaps on this encounter together: MS-DRG 689 → 690 (RW -0.3508).

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 (%)	27.0	echo LVEF 27% · echo ECH-000050 · 2026-05-19 12:02
Highest BNP this stay (pg/mL)	52.0	BNP 52 pg/mL · lab LAB-003597 · 2026-11-09 13:02
Prior heart failure on the problem list / history	True	history: heart failure with reduced ejection fraction · history HX-000040

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=52.0, 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=27.0, 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=27.0, 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 #2176); 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-00106   Patient: Dmitri Greaves   To: Dr. Cyrus Ellingham

Clinical indicators from the health record:
- Documented in the record: "acute on chronic systolic heart failure" [Progress note DOC-000358]
- echo LVEF 27% (2026-05-19 12:02) [echo ECH-000050]
- BNP 52 pg/mL (2026-11-09 13:02) [lab LAB-003597]
- history: heart failure with reduced ejection fraction [history HX-000040]

Question:
The indicators above are documented in this encounter. Could you clarify the type and acuity of the documented heart failure?

Response options (select one or write your own):
( ) Acute on chronic systolic heart failure: confirmed (please document the supporting clinical information)
( ) Chronic systolic heart failure (HFrEF)
( ) 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.
Hyponatraemia · Clinical judgement required Clinical judgement required: Low sodium without documented treatment or repeat values; clinical significance is a clinician judgement.
Malnutrition · Specificity gap Documented “malnourished” (E46); criteria support the more specific Moderate (non-severe) protein-calorie malnutrition (chronic illness context) (E44.0).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2176	2026-11-14T20:57:25	system:llm system	`llm.call`	ENC-00106, ENC-00106.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry a989a669ef1e
1350	2026-11-14T19:24:30	system:llm system	`llm.call`	ENC-00106, ENC-00106.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry 778638533b3b
608	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00106, ENC-00106.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry f855f3afb4d6