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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Florian Yardley: Heart failure

ENC-00176 · 49F · Cardiology · admitted Sat Nov 07, 2026 07:36 PM · in hospital · attending Dr. Wes Merriweather · resident Dr. Elena Nakashima

Clinical judgement required Clinical judgement required Open In hospital: concurrent review Resident note awaiting attending cosign

Clinical judgement required: Only one acute indicator; acuity needs clinical judgement.

Documented vs supported

Documented: “heart failure” · I50.9 Heart failure, unspecified
Criteria support: no conclusion: clinical judgement required
Outcome: Only one acute indicator; acuity needs clinical judgement
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.

Clinical judgement required. The rule does not conclude here. A CDI specialist may send an open query or dismiss the finding; nothing is proposed as fact.

Effect if the clinician agrees (illustrative)

Change: no projected change (clinician judgement)
Secondary-diagnosis level: 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, N18.32, D62, E78.5, K21.9, I10
Codes after: I50.9, N18.32, D62, E78.5, K21.9, I10

All open gaps on this encounter together: MS-DRG 292 → 292 (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

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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Latest LVEF within 12 months (%)	59.0	echo LVEF 59% · echo ECH-000081 · 2026-11-08 12:36
IV loop diuretic given this stay	True	furosemide 40 mg IV · med MED-000698 · 2026-11-07 22:36
Highest BNP this stay (pg/mL)	40.0	BNP 40 pg/mL · lab LAB-006038 · 2026-11-07 20:36
Prior heart failure on the problem list / history	True	history: heart failure with preserved ejection fraction · history HX-000062

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=40.0, ntprobnp_max=unknown, t.bnp=100, t.ntprobnp=300	false
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=True, new_o2=False, np_elevated=False	1
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=59.0, 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=59.0, 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=1, hf_history=True	unknown
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=unknown, hf_type=diastolic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	acuity=unknown, hf_type=diastolic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	acuity=unknown, hf_type=diastolic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	acuity=unknown, hf_type=diastolic	unknown
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	acuity=unknown, hf_type=diastolic	unknown
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	acuity=unknown, hf_type=diastolic	unknown
outcome: one_indicator	`acute_count == 1`	acute_count=1	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2301); 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-00176   Patient: Florian Yardley   To: Dr. Wes Merriweather

Clinical indicators from the health record:
- Documented in the record: "heart failure" [History and physical DOC-000590]
- echo LVEF 59% (2026-11-08 12:36) [echo ECH-000081]
- furosemide 40 mg IV (2026-11-07 22:36) [med MED-000698]
- BNP 40 pg/mL (2026-11-07 20:36) [lab LAB-006038]
- history: heart failure with preserved ejection fraction [history HX-000062]

Question:
Could you review the cardiac indicators above and clarify the type and acuity of the heart failure, if clinically appropriate?

Response options (select one or write your own):
( ) 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.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2301	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00176, ENC-00176.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 5170713a20e8
1475	2026-11-14T19:24:32	system:llm system	`llm.call`	ENC-00176, ENC-00176.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 3fda7b1ee6ef
733	2026-11-14T18:29:07	system:llm system	`llm.call`	ENC-00176, ENC-00176.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b11cbc745b3f output d92db0ffdad6 entry 4a2d3b8932c0