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-00178

Quinn Kestrel: Heart failure

ENC-00178 · 50F · Hospital Medicine · admitted Tue Nov 10, 2026 11:09 AM · in hospital · attending Dr. Jalen Carrow

Clinical validation gap Criteria met Open In hospital: concurrent review

Documented “acute on chronic diastolic heart failure” (I50.33) is more specific than the criteria support (Chronic diastolic (HFpEF) heart failure, I50.32).

Documented vs supported

Documented: “acute on chronic diastolic heart failure” · I50.33 Acute on chronic diastolic (congestive) heart failure
Criteria support: Chronic diastolic (HFpEF) heart failure · I50.32 Chronic diastolic (congestive) heart failure
Outcome: LVEF 65%, 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: I50.33 -> I50.32
Secondary-diagnosis level: MCC → CC
MS-DRG (illustrative): 193 Simple pneumonia and pleurisy with MCC → 194 Simple pneumonia and pleurisy with CC
Relative weight: 1.3144 → 0.8059 (-0.5085)
Codes before: J18.9, E46, N28.9, I50.33, D62, L89.159
Codes after: J18.9, E46, N28.9, D62, L89.159, I50.32

All open gaps on this encounter together: MS-DRG 193 → 193 (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

-0.5 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 (%)	65.0	echo LVEF 65% · echo ECH-000083 · 2026-11-11 16:09
Highest BNP this stay (pg/mL)	75.0	BNP 75 pg/mL · lab LAB-006103 · 2026-11-10 12:09
Prior heart failure on the problem list / history	True	history: heart failure with preserved ejection fraction · history HX-000064

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=75.0, 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=65.0, 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=65.0, 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=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	acuity=chronic, hf_type=diastolic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	acuity=chronic, hf_type=diastolic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	acuity=chronic, hf_type=diastolic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	acuity=chronic, hf_type=diastolic	false
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	acuity=chronic, hf_type=diastolic	false
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	acuity=chronic, hf_type=diastolic	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2307); 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-00178   Patient: Quinn Kestrel   To: Dr. Jalen Carrow

Clinical indicators from the health record:
- Documented in the record: "acute on chronic diastolic heart failure" [Progress note DOC-000598]
- echo LVEF 65% (2026-11-11 16:09) [echo ECH-000083]
- BNP 75 pg/mL (2026-11-10 12:09) [lab LAB-006103]
- history: heart failure with preserved ejection fraction [history HX-000064]

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 diastolic heart failure: confirmed (please document the supporting clinical information)
( ) Chronic diastolic heart failure (HFpEF)
( ) 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

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 · Clinical judgement required Clinical judgement required: Haemoglobin fell 1.4 g/dL without transfusion (between 1 and 2 g/dL).
Malnutrition · Clinical judgement required Clinical judgement required: Only one consensus characteristic documented; two are required.
Pressure injury · Specificity gap Documented “sacral pressure ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, stage 3 (L89.153).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2307	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00178, ENC-00178.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry 460bfcc86836
1481	2026-11-14T19:24:32	system:llm system	`llm.call`	ENC-00178, ENC-00178.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry 5b7bab1a5927
739	2026-11-14T18:29:07	system:llm system	`llm.call`	ENC-00178, ENC-00178.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 3a3f02e0b5de output d9932f2bccc8 entry e5a691744319