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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Sana Ingram: Acute kidney injury

ENC-00027 · 56M · Pulmonology · admitted Mon Nov 09, 2026 04:42 PM · in hospital · attending Dr. Jalen Carrow · resident Dr. Camila Oyelaran

Specificity gap Criteria met Open In hospital: concurrent review Resident note awaiting attending cosign

Documented “worsening renal function” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 3) (N17.9).

Documented vs supported

Documented: “worsening renal function” · N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency)
Criteria support: Acute kidney injury (KDIGO stage 3) · N17.9 Acute kidney failure, unspecified
Outcome: AKI criteria met, KDIGO stage 3
Note: ICD-10-CM does not code the KDIGO stage; the stage is shown so the clinician can document it.
Rule: Acute kidney injury (KDIGO staging) v2026.11-1
Published source: KDIGO Clinical Practice Guideline for Acute Kidney Injury (Kidney Int Suppl 2012;2:19-36) (2012), Recommendations 2.1.1 (definition) and 2.1.2 (staging), Table 2 · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: N28.9 -> N17.9
Secondary-diagnosis level: non-CC → CC
MS-DRG (illustrative): 191 Chronic obstructive pulmonary disease with CC → 191 Chronic obstructive pulmonary disease with CC
Relative weight: 0.8430 → 0.8430 (+0.0000)
Codes before: J44.1, N18.4, N28.9, D62, E78.5, I10, K21.9
Codes after: J44.1, N18.4, D62, E78.5, I10, K21.9, N17.9

All open gaps on this encounter together: MS-DRG 191 → 190 (RW +0.2647).

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
Baseline creatinine (mg/dL); most recent pre-admission value within 365 days, else lowest this stay (presumed) most recent pre-admission value within 365 days	1.93	creatinine 1.93 mg/dL (pre-admission) · lab LAB-000923 · 2026-10-06 10:05
Whether a pre-admission baseline exists	True	pre-admission creatinine on file · lab LAB-000923 · 2026-10-06 10:05
Peak creatinine this stay (mg/dL)	4.57	creatinine 4.57 mg/dL (peak this stay) · lab LAB-000925 · 2026-11-10 05:00
Peak / baseline peak / baseline	2.368	creatinine 4.57 mg/dL (peak this stay) · lab LAB-000925 · 2026-11-10 05:00 creatinine 1.93 mg/dL (pre-admission) · lab LAB-000923 · 2026-10-06 10:05
Largest creatinine rise between two values within 48 h (mg/dL) largest rise between two values within 48 hours	1.01	creatinine 3.56 · lab LAB-000924 · 2026-11-09 17:42 creatinine 4.57 · lab LAB-000925 · 2026-11-10 05:00

Rule trace (inputs, thresholds, outcome)

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=2.368, creat_rise_48h=1.01, t.ratio_s1=1.5, t.rise_abs=0.3, t.uo_s1_h=6, uo_hours_lt_0_5=unknown	true
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	anuria_hours=unknown, creat_peak=4.57, creat_ratio=2.368, meets_definition=True, rrt_started=False, t.anuria_h=12, t.ratio_s3=3.0, t.scr_s3=4.0, t.uo_s3_h=24, uo_hours_lt_0_3=unknown	true
derived: stage2	`creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false)`	creat_ratio=2.368, t.ratio_s2=2.0, t.uo_s2_h=12, uo_hours_lt_0_5=unknown	true
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	meets_definition=True, stage2=True, stage3=True	3
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=1.01, rrt_started=False, t.rise_abs=0.3	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	baseline_independent=True, stage=3	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2005); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: kidney function documentation
Encounter: ENC-00027   Patient: Sana Ingram   To: Dr. Jalen Carrow

Clinical indicators from the health record:
- Documented in the record: "worsening renal function" [Progress note DOC-000091]
- creatinine 1.93 mg/dL (pre-admission) (2026-10-06 10:05) [lab LAB-000923]
- creatinine 4.57 mg/dL (peak this stay) (2026-11-10 05:00) [lab LAB-000925]
- creatinine 3.56 (2026-11-09 17:42) [lab LAB-000924]

Question:
Based on your clinical judgement and the indicators above, can the kidney diagnosis being monitored and treated be further specified?

Response options (select one or write your own):
( ) Acute kidney injury (please specify stage, if known)
( ) 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

Chronic kidney disease · Clinical validation gap Documented “CKD stage 4” (N18.4) conflicts with what the criteria support (Chronic kidney disease stage 3b, N18.32).
Pressure injury · Specificity gap Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2005	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00027, ENC-00027.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt aa134379ab6c output 968dc8741b13 entry b6c080cdcf51
1179	2026-11-14T19:24:28	system:llm system	`llm.call`	ENC-00027, ENC-00027.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt aa134379ab6c output 968dc8741b13 entry 69f02e63c0fc
437	2026-11-14T18:29:03	system:llm system	`llm.call`	ENC-00027, ENC-00027.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt aa134379ab6c output 968dc8741b13 entry a4b791d17053