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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Vera Rourke: Heart failure

ENC-00157 · 87M · Hospital Medicine · admitted Wed Nov 04, 2026 08:39 AM · discharged Wed Nov 11, 2026 12:43 PM · attending Dr. Jalen Carrow

Specificity gap Criteria met Open

Documented “systolic heart failure” (I50.20); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).

Documented vs supported

Documented: “systolic heart failure” · I50.20 Unspecified systolic (congestive) heart failure
Criteria support: Acute on chronic systolic (HFrEF) heart failure · I50.23 Acute on chronic systolic (congestive) heart failure
Outcome: LVEF 25% with 2 acute indicators and prior heart failure
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: I50.20 -> I50.23
Secondary-diagnosis level: CC → MCC
MS-DRG (illustrative): 194 Simple pneumonia and pleurisy with CC → 193 Simple pneumonia and pleurisy with MCC
Relative weight: 0.8059 → 1.3144 (+0.5085)
Codes before: J18.9, N28.9, I50.20, E78.5
Codes after: J18.9, N28.9, E78.5, I50.23

All open gaps on this encounter together: MS-DRG 194 → 193 (RW +0.5085).

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 (%)	25.0	echo LVEF 25% · echo ECH-000073 · 2026-11-05 12:39
IV loop diuretic given this stay	True	furosemide 40 mg IV · med MED-000630 · 2026-11-04 20:00 furosemide 40 mg IV · med MED-000631 · 2026-11-05 08:00 furosemide 40 mg IV · med MED-000632 · 2026-11-05 20:00 furosemide 40 mg IV · med MED-000633 · 2026-11-06 08:00
Highest BNP this stay (pg/mL)	2127.0	BNP 2127 pg/mL · lab LAB-005353 · 2026-11-04 09:39
Prior heart failure on the problem list / history	True	history: heart failure with reduced ejection fraction · history HX-000056

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=2127.0, 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=False, np_elevated=True	2
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=25.0, 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=25.0, 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=2, hf_history=True	acute on 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=acute on chronic, hf_type=systolic	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2264); 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-00157   Patient: Vera Rourke   To: Dr. Jalen Carrow

Clinical indicators from the health record:
- Documented in the record: "systolic heart failure" [Progress note DOC-000529]
- echo LVEF 25% (2026-11-05 12:39) [echo ECH-000073]
- furosemide 40 mg IV (2026-11-04 20:00) [med MED-000630]
- furosemide 40 mg IV (2026-11-05 08:00) [med MED-000631]
- furosemide 40 mg IV (2026-11-05 20:00) [med MED-000632]
- furosemide 40 mg IV (2026-11-06 08:00) [med MED-000633]
- BNP 2127 pg/mL (2026-11-04 09:39) [lab LAB-005353]
- history: heart failure with reduced ejection fraction [history HX-000056]

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 on chronic systolic heart failure (HFrEF)
( ) 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 · Specificity gap Documented “renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 3) (N17.9).
Acute blood loss anaemia · Specificity gap Criteria support Acute blood loss anemia (D62); no corresponding diagnosis is documented.
Obesity · Specificity gap Criteria support Obesity, class 1 (E66.811); no corresponding diagnosis is documented.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2264	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00157, ENC-00157.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry aee131c382c4
1438	2026-11-14T19:24:31	system:llm system	`llm.call`	ENC-00157, ENC-00157.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 5769a6c39e7c
696	2026-11-14T18:29:06	system:llm system	`llm.call`	ENC-00157, ENC-00157.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 47d04778fe15