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-00065
Lena Upfield: Chronic kidney disease
ENC-00065 · 51M · Hospital Medicine · admitted Tue Nov 10, 2026 03:47 PM · in hospital · attending Dr. Rosalind Quillan · resident Dr. Camila Oyelaran
Specificity gap Criteria met Open
In hospital: concurrent review Resident note awaiting attending cosign
Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
Documented vs supported
- Documented
- “chronic kidney disease” · 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 25.6 (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)
- 193 Simple pneumonia and pleurisy with MCC → 193 Simple pneumonia and pleurisy with MCC
- Relative weight
- 1.3144 → 1.3144 (+0.0000)
- Codes before
- J18.9, E43, N18.9, I50.30, R09.02, D64.9
- Codes after
- J18.9, E43, I50.30, R09.02, D64.9, N18.4
All open gaps on this encounter together: MS-DRG 193 → 193 (RW +0.0000). The grouping does not change; the record becomes accurate.
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 2.88 -> eGFR 26
creatinine 3.5 -> eGFR 20
|
| Days between the earliest and latest pre-admission eGFR values | 254 |
creatinine 2.88 mg/dL -> eGFR 26 (CKD-EPI 2021)
creatinine 3.5 mg/dL -> eGFR 20 (CKD-EPI 2021)
|
| Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 25.6 |
creatinine 2.88 mg/dL -> eGFR 26 (CKD-EPI 2021)
|
| Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 20.3 |
creatinine 3.5 mg/dL -> eGFR 20 (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=254, t.chronic_days=90 | true |
| derived: staging_egfr | max(egfr_early, egfr_late) |
egfr_early=25.6, egfr_late=20.3 | 25.6 |
| derived: both_below_60 | egfr_early < t.g2 and egfr_late < t.g2 |
egfr_early=25.6, egfr_late=20.3, 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=25.6, 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=25.6, egfr_late=20.3, t.g2=60 | false |
| outcome: g1_g2 | staging_egfr >= t.g2 |
staging_egfr=25.6, 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 #2093); 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-00065 Patient: Lena Upfield To: Dr. Rosalind Quillan Clinical indicators from the health record: - Documented in the record: "chronic kidney disease" [History and physical DOC-000225] - creatinine 2.88 -> eGFR 26 (2025-12-03 09:15) [lab LAB-002188] - creatinine 3.5 -> eGFR 20 (2026-08-14 10:05) [lab LAB-002189] 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
- Acute blood loss anaemia · Specificity gap Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).
- Heart failure · Specificity gap Documented “diastolic heart failure” (I50.30); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
- Hyponatraemia · Specificity gap Criteria support Hyponatraemia (moderate) (E87.1); no corresponding diagnosis is documented.
- Malnutrition · Clinical validation gap Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (chronic illness context), E44.0).
- Acute respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2093 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00065, ENC-00065.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry cdba87e05ca6 |
| 1267 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00065, ENC-00065.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 08b40be842b0 |
| 525 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00065, ENC-00065.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 06d4ceaaa8a8 |