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 Thorne: Chronic kidney disease

ENC-00107 · 60F · Cardiology · admitted Sat Oct 31, 2026 09:40 PM · discharged Tue Nov 03, 2026 01:22 PM · attending Dr. Cyrus Ellingham · resident Dr. Noor Halvorsen

Clinical validation gap Criteria met Open

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 37.8 (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): 292 Heart failure and shock with CC → 292 Heart failure and shock with CC
Relative weight: 0.8490 → 0.8490 (+0.0000)
Codes before: I50.23, N18.4, N17.9, K21.9, E78.5
Codes after: I50.23, N17.9, K21.9, E78.5, N18.32

All open gaps on this encounter together: MS-DRG 292 → 291 (RW +0.4348).

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 1.58 -> eGFR 37 · lab LAB-003619 · 2026-01-13 09:15 creatinine 1.56 -> eGFR 38 · lab LAB-003620 · 2026-07-25 10:05
Days between the earliest and latest pre-admission eGFR values	193	creatinine 1.58 mg/dL -> eGFR 37 (CKD-EPI 2021) · lab LAB-003619 · 2026-01-13 09:15 creatinine 1.56 mg/dL -> eGFR 38 (CKD-EPI 2021) · lab LAB-003620 · 2026-07-25 10:05
Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021)	37.3	creatinine 1.58 mg/dL -> eGFR 37 (CKD-EPI 2021) · lab LAB-003619 · 2026-01-13 09:15
Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021)	37.8	creatinine 1.56 mg/dL -> eGFR 38 (CKD-EPI 2021) · lab LAB-003620 · 2026-07-25 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=193, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=37.3, egfr_late=37.8	37.8
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=37.3, egfr_late=37.8, 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=37.8, 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=37.3, egfr_late=37.8, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=37.8, 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 #2180); 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-00107   Patient: Sana Thorne   To: Dr. Cyrus Ellingham

Clinical indicators from the health record:
- Documented in the record: "CKD stage 4" [History and physical DOC-000360]
- creatinine 1.58 -> eGFR 37 (2026-01-13 09:15) [lab LAB-003619]
- creatinine 1.56 -> eGFR 38 (2026-07-25 10:05) [lab LAB-003620]

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 · Clinical validation gap Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
Malnutrition · Specificity gap Criteria support Severe protein-calorie malnutrition (acute illness context) (E43); no corresponding diagnosis is documented.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2180	2026-11-14T20:57:25	system:llm system	`llm.call`	ENC-00107, ENC-00107.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 8d382c252100
1354	2026-11-14T19:24:30	system:llm system	`llm.call`	ENC-00107, ENC-00107.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 7680cd0e960d
612	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00107, ENC-00107.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 95448cb62120