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: Pressure 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

Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.

Documented vs supported

Documented: not documented
Criteria support: Pressure injury of sacral region, stage 4 · L89.154 Pressure ulcer of sacral region, stage 4
Outcome: Wound nurse documents stage 4, sacral
Rule: Pressure injury stage (sacral region) v2026.11-1
Published source: NPIAP Pressure Injury Stages (revised staging system) (2016), Stage 1-4, unstageable, deep tissue pressure injury definitions · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: add L89.154
Secondary-diagnosis level: — → MCC
MS-DRG (illustrative): 191 Chronic obstructive pulmonary disease with CC → 190 Chronic obstructive pulmonary disease with MCC
Relative weight: 0.8430 → 1.1077 (+0.2647)
Codes before: J44.1, N18.4, N28.9, D62, E78.5, I10, K21.9
Codes after: J44.1, N18.4, N28.9, D62, E78.5, I10, K21.9, L89.154

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

1.0 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
Stage quoted from the wound-care note	4	“Stage: 4” · Wound care note DOC-000089, p. 1, line 5 · quoted span verified Show the quote in the note WOUND CARE NOTE Patient: Sana Ingram MRN: MRN52022739 Location: sacrum Stage: 4 (NPIAP) Description: full-thickness tissue loss with palpable bone. Size: 4.7 x 3.4 x 1.2 cm. Plan: offloading every 2 hours, foam dressing, nutrition consult.
Site quoted from the wound-care note	sacral	“Location: sacrum” · Wound care note DOC-000089, p. 1, line 4 · quoted span verified Show the quote in the note WOUND CARE NOTE Patient: Sana Ingram MRN: MRN52022739 Location: sacrum Stage: 4 (NPIAP) Description: full-thickness tissue loss with palpable bone. Size: 4.7 x 3.4 x 1.2 cm. Plan: offloading every 2 hours, foam dressing, nutrition …

Rule trace (inputs, thresholds, outcome)

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=sacral	true
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=4	false
outcome: other_site	`wound_site != 'sacral'`	wound_site=sacral	false
outcome: stage1	`sacral and wound_stage == '1'`	sacral=True, wound_stage=4	false
outcome: stage2	`sacral and wound_stage == '2'`	sacral=True, wound_stage=4	false
outcome: stage3	`sacral and wound_stage == '3'`	sacral=True, wound_stage=4	false
outcome: stage4	`sacral and wound_stage == '4'`	sacral=True, wound_stage=4	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2007); clinical indicators and answer options assembled by code from the rule and the record.

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

Clinical indicators from the health record:
- "Stage: 4" (2026-11-10 18:42) [Wound care note DOC-000089, p. 1, line 5]
- "Location: sacrum" (2026-11-10 18:42) [Wound care note DOC-000089, p. 1, line 4]

Question:
The wound-care documentation above is part of this encounter. Based on your clinical judgement, can a related diagnosis be documented, including site and stage?

Response options (select one or write your own):
( ) Pressure ulcer of sacral region, stage 4
( ) 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

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

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2007	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00027, ENC-00027.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 94204f2cd745 output 29146ed5aa61 entry abfe8c38966f
1181	2026-11-14T19:24:28	system:llm system	`llm.call`	ENC-00027, ENC-00027.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 94204f2cd745 output 29146ed5aa61 entry 41b241eab06f
439	2026-11-14T18:29:03	system:llm system	`llm.call`	ENC-00027, ENC-00027.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 94204f2cd745 output 29146ed5aa61 entry 93fd25f695c6