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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Elena Okafor: Chronic kidney disease

ENC-00054 · 49M · Hospital Medicine · admitted Mon Nov 09, 2026 10:24 AM · in hospital · attending Dr. Wes Merriweather · resident Dr. Greta Kowalczyk

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

Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).

Documented vs supported

Documented: “CKD” · N18.9 Chronic kidney disease, unspecified
Criteria support: Chronic kidney disease stage 4 · N18.4 Chronic kidney disease, stage 4 (severe)
Outcome: Two eGFR values >=90 days apart; staging value 22.3 (G4)
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: N18.9 -> N18.4
Secondary-diagnosis level: non-CC → CC
MS-DRG (illustrative): 871 Septicemia or severe sepsis without MV >96 hours with MCC → 871 Septicemia or severe sepsis without MV >96 hours with MCC
Relative weight: 1.9425 → 1.9425 (+0.0000)
Codes before: A41.9, J18.9, E46, N18.9
Codes after: A41.9, J18.9, E46, N18.4

All open gaps on this encounter together: MS-DRG 871 → 193 (RW -0.6281).

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
Number of pre-admission eGFR values within 2 years (inpatient values during acute illness are not used)	2	creatinine 3.73 -> eGFR 19 · lab LAB-001825 · 2026-01-29 09:15 creatinine 3.26 -> eGFR 22 · lab LAB-001826 · 2026-07-24 10:05
Days between the earliest and latest pre-admission eGFR values	176	creatinine 3.73 mg/dL -> eGFR 19 (CKD-EPI 2021) · lab LAB-001825 · 2026-01-29 09:15 creatinine 3.26 mg/dL -> eGFR 22 (CKD-EPI 2021) · lab LAB-001826 · 2026-07-24 10:05
Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021)	19.0	creatinine 3.73 mg/dL -> eGFR 19 (CKD-EPI 2021) · lab LAB-001825 · 2026-01-29 09:15
Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021)	22.3	creatinine 3.26 mg/dL -> eGFR 22 (CKD-EPI 2021) · lab LAB-001826 · 2026-07-24 10:05

Rule trace (inputs, thresholds, outcome)

Rule trace (rule ckd v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=176, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=19.0, egfr_late=22.3	22.3
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=19.0, egfr_late=22.3, 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=22.3, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G4
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=19.0, egfr_late=22.3, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=22.3, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G4	false
outcome: g3b	`category == 'G3b'`	category=G4	false
outcome: g4	`category == 'G4'`	category=G4	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2066); 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-00054   Patient: Elena Okafor   To: Dr. Wes Merriweather

Clinical indicators from the health record:
- Documented in the record: "CKD" [History and physical DOC-000189]
- creatinine 3.73 -> eGFR 19 (2026-01-29 09:15) [lab LAB-001825]
- creatinine 3.26 -> eGFR 22 (2026-07-24 10:05) [lab LAB-001826]

Question:
Based on your clinical judgement and the indicators above, can the chronic kidney condition be further specified, including stage if known?

Response options (select one or write your own):
( ) Chronic kidney disease stage 3b (eGFR 30-44)
( ) Chronic kidney disease stage 4 (eGFR 15-29)
( ) 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

Malnutrition · Specificity gap Documented “malnourished” (E46); criteria support the more specific Severe protein-calorie malnutrition (acute illness context) (E43).
Sepsis · Clinical validation gap Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2066	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00054, ENC-00054.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 689de48a817e
1240	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00054, ENC-00054.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 28a5d0fd6186
498	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00054, ENC-00054.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 8a278bbda4de