P13 KE-P13 · outpatient visit

One row per condition family: what the record supports under the published definition, what the note states, the visit's diagnosis entries, and an assessment. Codes are coded from the signed documentation; the software never assigns one.

Library check LRUN-00013 · library_default_set@1.0 · library-engine 1.0 · replay 6affe6074e8e9916… · Data (JSON)

Condition families for this encounter (3)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Severe hypercholesterolaemia (LDL) measured	`aha2018_severe_hypercholesterolaemia@1.0` Draft · pending review LDL-C ≥190 mg/dL (≥4.9 mmol/L) ldl cholesterol 204 mg/dL 2026-11-12 13:05 · LM-P13-03 Window: 730 days before the check. Another published definition (`atp3_ldl@1.0`) gives: Very high (≥190 mg/dL). Citation Severe hypercholesterolaemia, LDL-C ≥190 mg/dL (2018 AHA/ACC cholesterol guideline) aha2018_severe_hypercholesterolaemia@1.0 Severe Hypercholesterolemia (LDL-C ≥190 mg/dL [≥4.9 mmol/L]) American Heart Association / American College of Cardiology and partner societies, 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol (2018) · Section 4.2 heading; Top 10 Take-Home Message 4 · source Not encoded: 'Primary' (excluding secondary causes) is not assessed. Age 20-75 limits of the treatment recommendation are not encoded (only ≥20). Persistence or untreated status of the LDL is not checked.	Hyperlipidemia	None entered	Supported and specific
Code-family reference: Severe hypercholesterolaemia (LDL) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E78` Disorders of lipoprotein metabolism and other lipidemias: distinguishes pure hypercholesterolaemia, unspecified or familial (homozygous, heterozygous, unspecified) (18 codes in the category). `E78.00` Pure hypercholesterolemia, unspecified `E78.010` Homozygous familial hypercholesterolemia [HoFH] `E78.011` Heterozygous familial hypercholesterolemia [HeFH] `E78.019` Familial hypercholesterolemia, unspecified `E78.1` Pure hyperglyceridemia `E78.2` Mixed hyperlipidemia `E78.3` Hyperchylomicronemia `E78.41` Elevated Lipoprotein(a) `E78.49` Other hyperlipidemia `E78.5` Hyperlipidemia, unspecified `E78.6` Lipoprotein deficiency `E78.70` Disorder of bile acid and cholesterol metabolism, unspecified `E78.71` Barth syndrome `E78.72` Smith-Lemli-Opitz syndrome `E78.79` Other disorders of bile acid and cholesterol metabolism `E78.81` Lipoid dermatoarthritis `E78.89` Other lipoprotein metabolism disorders `E78.9` Disorder of lipoprotein metabolism, unspecified Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).
Prediabetes measured	`ada2026_prediabetes@1.0` Draft · pending review Prediabetes range (A1C 5.7–6.4%, IFG 100–125 mg/dL or IGT 140–199 mg/dL) hba1c 6 % 2026-11-12 13:05 · LM-P13-02 Window: 365 days before the check. Citation Prediabetes ranges (ADA Standards of Care 2026) ada2026_prediabetes@1.0 A1C 5.7–6.4% (39–47 mmol/mol); FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (IFG); 2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) (IGT) American Diabetes Association Professional Practice Committee, 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes—2026 (2026) · Table 2.2 Criteria defining prediabetes in nonpregnant individuals · source Contested: Other bodies (for example WHO) are understood to use a different impaired fasting glucose range and not to use an A1C prediabetes range; those texts were not opened, so no other thresholds are recorded. Review item. Not encoded: ADA does not require confirmation for prediabetes in Table 2.2; none is applied. A1C reliability conditions are not checked (see ada2026_diabetes). Only the most recent result of each test is used.	Prediabetes	`R73.03` Prediabetes (visit diagnosis list (synthetic))	Supported and specific
Code-family reference: Prediabetes Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `R73` Elevated blood glucose level: distinguishes R73.01 impaired fasting glucose, R73.02 impaired glucose tolerance (oral), R73.03 prediabetes, R73.09 other abnormal glucose, R73.9 hyperglycaemia unspecified (5 codes in the category). `R73.01` Impaired fasting glucose `R73.02` Impaired glucose tolerance (oral) `R73.03` Prediabetes `R73.09` Other abnormal glucose `R73.9` Hyperglycemia, unspecified Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).
Diabetes mellitus measured	`ada2026_diabetes@1.0` Draft · pending review Criteria not met hba1c 6 % 2026-11-12 13:05 · LM-P13-02 Window: 730 days before the check. Citation Diabetes diagnostic thresholds and the confirmation rule (ADA Standards of Care 2026) ada2026_diabetes@1.0 Table 2.1: A1C ≥6.5% (≥48 mmol/mol); FPG ≥126 mg/dL (≥7.0 mmol/L); 2-h PG ≥200 mg/dL (≥11.1 mmol/L) during OGTT; random plasma glucose ≥200 mg/dL (≥11.1 mmol/L) with classic symptoms of hyperglycemia or hyperglycemic crisis. In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal results from different tests ... or the same test at two different time points. American Diabetes Association Professional Practice Committee, 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes—2026 (2026) · Table 2.1 Criteria for the diagnosis of diabetes in nonpregnant individuals · source Not encoded: Type of diabetes (type 1, type 2, other) is not assessed. Conditions that make A1C unreliable (some haemoglobin variants, pregnancy, G6PD deficiency, HIV, anaemia, haemodialysis, erythropoietin; recommendation 2.4 and text) are not checked: A1C results are used as sent. No maximum interval between the two abnormal results is stated by the source and none is applied. Whether the test method is NGSP-certified and whether a fasting sample was truly fasting are asserted by the sender through the analyte name. When two different tests are discordant ADA advises repeating the abnormal test; this entry simply reports one abnormal result.	Not stated	None entered	Nothing to act on
Code-family reference: Diabetes mellitus Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E11` Type 2 diabetes mellitus: distinguishes type 2 diabetes with or without complications by body system (kidney, eye, nerve, circulatory, skin, oral, hypoglycaemia, hyperglycaemia, ketoacidosis, hyperosmolarity), long-term drug use is separate (Z79) (87 codes in the category). 87 codes; see the official files `E10` Type 1 diabetes mellitus: distinguishes type 1 diabetes with the same complication axes as E11 (87 codes in the category). 87 codes; see the official files Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).