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-00122
Bodhi Foxhall: Heart failure
ENC-00122 · 47M · Hospital Medicine · admitted Thu Nov 05, 2026 09:13 PM · discharged Mon Nov 09, 2026 10:39 AM · attending Dr. Kenji Stavros
Specificity gap Criteria met Open
Documented “heart failure” (I50.9); criteria support the more specific Acute systolic (HFrEF) heart failure (I50.21).
Documented vs supported
- Documented
- “heart failure” · I50.9 Heart failure, unspecified
- Criteria support
- Acute systolic (HFrEF) heart failure · I50.21 Acute systolic (congestive) heart failure
- Outcome
- LVEF 21% 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
- I50.9 -> I50.21
- Secondary-diagnosis level
- non-CC → MCC
- MS-DRG (illustrative)
- 689 Kidney and urinary tract infections with MCC → 689 Kidney and urinary tract infections with MCC
- Relative weight
- 1.1603 → 1.1603 (+0.0000)
- Codes before
- N39.0, E43, N17.9, I50.9, J96.01, D64.9, E11.9, I10, K21.9
- Codes after
- N39.0, E43, N17.9, J96.01, D64.9, E11.9, I10, K21.9, I50.21
All open gaps on this encounter together: MS-DRG 689 → 689 (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
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 |
|---|---|---|
| Latest LVEF within 12 months (%) | 21.0 |
echo LVEF 21%
|
| IV loop diuretic given this stay | True |
furosemide 40 mg IV
furosemide 40 mg IV
furosemide 40 mg IV
furosemide 40 mg IV
|
| Highest BNP this stay (pg/mL) | 698.0 |
BNP 698 pg/mL
|
| Supplemental oxygen started this stay without home oxygen supplemental oxygen started this stay without home oxygen on file |
True |
O2 6 L/min (nasal cannula)
|
Rule trace (inputs, thresholds, outcome)
| 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=698.0, 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=21.0, 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=21.0, 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 #2201); 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-00122 Patient: Bodhi Foxhall To: Dr. Kenji Stavros Clinical indicators from the health record: - Documented in the record: "heart failure" [Progress note DOC-000413] - echo LVEF 21% (2026-11-06 21:13) [echo ECH-000059] - furosemide 40 mg IV (2026-11-06 08:00) [med MED-000483] - furosemide 40 mg IV (2026-11-06 20:00) [med MED-000484] - furosemide 40 mg IV (2026-11-07 08:00) [med MED-000485] - furosemide 40 mg IV (2026-11-07 20:00) [med MED-000486] - BNP 698 pg/mL (2026-11-05 22:13) [lab LAB-004144] - O2 6 L/min (nasal cannula) (2026-11-05 21:43) [vital VIT-011846] 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 kidney injury · Clinical validation gap Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
- Acute blood loss anaemia · Specificity gap Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).
- Malnutrition · Clinical validation gap Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2201 | 2026-11-14T20:57:25 | system:llm system |
llm.call |
ENC-00122, ENC-00122.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 96579319bc1c |
| 1375 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00122, ENC-00122.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 8c2c95507152 |
| 633 | 2026-11-14T18:29:06 | system:llm system |
llm.call |
ENC-00122, ENC-00122.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 6aae63e7b8ee |