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-00027
Sana Ingram: Chronic kidney disease
ENC-00027 · 56M · Pulmonology · admitted Mon Nov 09, 2026 04:42 PM · in hospital · attending Dr. Jalen Carrow · resident Dr. Camila Oyelaran
Clinical validation gap Criteria met Open
In hospital: concurrent review Resident note awaiting attending cosign
Documented “CKD stage 4” (N18.4) conflicts with what the criteria support (Chronic kidney disease stage 3b, N18.32).
Documented vs supported
- Documented
- “CKD stage 4” · N18.4 Chronic kidney disease, stage 4 (severe)
- Criteria support
- Chronic kidney disease stage 3b · N18.32 Chronic kidney disease, stage 3b
- Outcome
- Two eGFR values >=90 days apart, both below 60; staging value 40.1 (G3b)
- Rule
- Chronic kidney disease stage (eGFR, CKD-EPI 2021) v2026.11-1
- Published source
- KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (2024), Chapter 1, Table 1 (definition: abnormality for a minimum of 3 months) and Table 2 (GFR categories) · source (checked 2026-11-14)
Effect if the clinician agrees (illustrative)
- Change
- N18.4 -> N18.32
- Secondary-diagnosis level
- CC → non-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, N28.9, D62, E78.5, I10, K21.9, N18.32
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.
| Input | Value | Source |
|---|---|---|
| Number of pre-admission eGFR values within 2 years (inpatient values during acute illness are not used) | 2 |
creatinine 1.94 -> eGFR 40
creatinine 1.93 -> eGFR 40
|
| Days between the earliest and latest pre-admission eGFR values | 324 |
creatinine 1.94 mg/dL -> eGFR 40 (CKD-EPI 2021)
creatinine 1.93 mg/dL -> eGFR 40 (CKD-EPI 2021)
|
| Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 39.9 |
creatinine 1.94 mg/dL -> eGFR 40 (CKD-EPI 2021)
|
| Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 40.1 |
creatinine 1.93 mg/dL -> eGFR 40 (CKD-EPI 2021)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: chronic | egfr_n >= 2 and egfr_span_days >= t.chronic_days |
egfr_n=2, egfr_span_days=324, t.chronic_days=90 | true |
| derived: staging_egfr | max(egfr_early, egfr_late) |
egfr_early=39.9, egfr_late=40.1 | 40.1 |
| derived: both_below_60 | egfr_early < t.g2 and egfr_late < t.g2 |
egfr_early=39.9, egfr_late=40.1, t.g2=60 | true |
| derived: category | case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5') |
staging_egfr=40.1, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 | G3b |
| outcome: duration_not_shown | not chronic |
chronic=True | false |
| outcome: straddles_60 | not both_below_60 and min(egfr_early, egfr_late) < t.g2 |
both_below_60=True, egfr_early=39.9, egfr_late=40.1, t.g2=60 | false |
| outcome: g1_g2 | staging_egfr >= t.g2 |
staging_egfr=40.1, t.g2=60 | false |
| outcome: g3a | category == 'G3a' |
category=G3b | false |
| outcome: g3b | category == 'G3b' |
category=G3b | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2006); clinical indicators and answer options assembled by code from the rule and the record.
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DOCUMENTATION QUERY (draft) Title: Clarification request: chronic kidney documentation Encounter: ENC-00027 Patient: Sana Ingram To: Dr. Jalen Carrow Clinical indicators from the health record: - Documented in the record: "CKD stage 4" [History and physical DOC-000090] - creatinine 1.94 -> eGFR 40 (2025-11-16 09:15) [lab LAB-000922] - creatinine 1.93 -> eGFR 40 (2026-10-06 10:05) [lab LAB-000923] Question: The indicators above are documented in this encounter. Could you clarify the status and stage of the documented chronic kidney diagnosis? Response options (select one or write your own): ( ) CKD stage 4: confirmed (please document the supporting clinical information) ( ) Chronic kidney disease stage 3a (eGFR 45-59) ( ) Chronic kidney disease stage 3b (eGFR 30-44) ( ) 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 “worsening renal function” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 3) (N17.9).
- Pressure injury · Specificity gap Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2006 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00027, ENC-00027.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 0b4e2c86d2f5 |
| 1180 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00027, ENC-00027.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 6972ffdd0248 |
| 438 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00027, ENC-00027.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 64ea763916a8 |