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-00125
Dmitri Jessup: Heart failure
ENC-00125 · 49M · Cardiology · admitted Fri Nov 06, 2026 04:00 PM · discharged Mon Nov 09, 2026 02:18 PM · attending Dr. Cyrus Ellingham
Specificity gap Criteria met Open
Documented “congestive heart failure” (I50.9); criteria support the more specific Acute diastolic (HFpEF) heart failure (I50.31).
Documented vs supported
- Documented
- “congestive heart failure” · I50.9 Heart failure, unspecified
- Criteria support
- Acute diastolic (HFpEF) heart failure · I50.31 Acute diastolic (congestive) heart failure
- Outcome
- LVEF 63% 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
- principal I50.9 -> I50.31
- Secondary-diagnosis level
- principal → principal
- MS-DRG (illustrative)
- 292 Heart failure and shock with CC → 292 Heart failure and shock with CC
- Relative weight
- 0.8490 → 0.8490 (+0.0000)
- Codes before
- I50.9, E46, N28.9, D62, I10, E78.5, K21.9
- Codes after
- I50.31, E46, N28.9, D62, I10, E78.5, K21.9
All open gaps on this encounter together: MS-DRG 292 → 291 (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.
| Input | Value | Source |
|---|---|---|
| Latest LVEF within 12 months (%) | 63.0 |
echo LVEF 63%
|
| 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) | 2099.0 |
BNP 2099 pg/mL
|
| Supplemental oxygen started this stay without home oxygen supplemental oxygen started this stay without home oxygen on file |
True |
O2 4 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=2099.0, 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=63.0, t.pres=50, t.ref=40 | diastolic |
| derived: improved | coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false) |
lvef=63.0, 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=diastolic | false |
| outcome: sys_aoc | hf_type == 'systolic' and acuity == 'acute on chronic' |
acuity=acute, hf_type=diastolic | false |
| outcome: sys_acute | hf_type == 'systolic' and acuity == 'acute' |
acuity=acute, hf_type=diastolic | false |
| outcome: sys_chronic | hf_type == 'systolic' and acuity == 'chronic' |
acuity=acute, hf_type=diastolic | false |
| outcome: dia_aoc | hf_type == 'diastolic' and acuity == 'acute on chronic' |
acuity=acute, hf_type=diastolic | false |
| outcome: dia_acute | hf_type == 'diastolic' and acuity == 'acute' |
acuity=acute, hf_type=diastolic | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2207); 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-00125 Patient: Dmitri Jessup To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "congestive heart failure" [History and physical DOC-000422] - echo LVEF 63% (2026-11-07 19:00) [echo ECH-000060] - furosemide 40 mg IV (2026-11-06 20:00) [med MED-000492] - furosemide 40 mg IV (2026-11-07 08:00) [med MED-000493] - furosemide 40 mg IV (2026-11-07 20:00) [med MED-000494] - furosemide 40 mg IV (2026-11-08 08:00) [med MED-000495] - BNP 2099 pg/mL (2026-11-06 17:00) [lab LAB-004245] - O2 4 L/min (nasal cannula) (2026-11-06 16:30) [vital VIT-012163] 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 diastolic heart failure (HFpEF) ( ) Acute on chronic diastolic heart failure (HFpEF) ( ) 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 judgement required Clinical judgement required: AKI criteria met only against a presumed baseline (no pre-admission creatinine on file).
- Acute blood loss anaemia · Clinical validation gap Documented “acute blood loss anemia” (D62) is more specific than the criteria support (Anemia (acute blood-loss criteria not met), D64.9).
- Malnutrition · Clinical judgement required Clinical judgement required: Only one consensus characteristic documented; two are required.
- Acute respiratory failure · Specificity gap Criteria support Acute respiratory failure with hypoxia (J96.01); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2207 | 2026-11-14T20:57:25 | system:llm system |
llm.call |
ENC-00125, ENC-00125.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry af2fe60d0586 |
| 1381 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00125, ENC-00125.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 56cf576e3cab |
| 639 | 2026-11-14T18:29:06 | system:llm system |
llm.call |
ENC-00125, ENC-00125.heart_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 35d11057056b |