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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Jun Kestrel: Acute kidney injury

ENC-00124 · 47M · Pulmonology · admitted Mon Nov 09, 2026 10:02 AM · in hospital · attending Dr. Gideon Zeller · resident Dr. Greta Kowalczyk

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

Criteria support Acute kidney injury (KDIGO stage 2) (N17.9); no corresponding diagnosis is documented.

Documented vs supported

Documented: not documented
Criteria support: Acute kidney injury (KDIGO stage 2) · N17.9 Acute kidney failure, unspecified
Outcome: AKI criteria met, KDIGO stage 2
Note: ICD-10-CM does not code the KDIGO stage; the stage is shown so the clinician can document it.
Rule: Acute kidney injury (KDIGO staging) v2026.11-1
Published source: KDIGO Clinical Practice Guideline for Acute Kidney Injury (Kidney Int Suppl 2012;2:19-36) (2012), Recommendations 2.1.1 (definition) and 2.1.2 (staging), Table 2 · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: add N17.9
Secondary-diagnosis level: — → CC
MS-DRG (illustrative): 190 Chronic obstructive pulmonary disease with MCC → 190 Chronic obstructive pulmonary disease with MCC
Relative weight: 1.1077 → 1.1077 (+0.0000)
Codes before: J44.1, L89.154, E78.5
Codes after: J44.1, L89.154, E78.5, N17.9

All open gaps on this encounter together: MS-DRG 190 → 190 (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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Baseline creatinine (mg/dL); most recent pre-admission value within 365 days, else lowest this stay (presumed) most recent pre-admission value within 365 days	1.35	creatinine 1.35 mg/dL (pre-admission) · lab LAB-004214 · 2026-08-08 10:05
Whether a pre-admission baseline exists	True	pre-admission creatinine on file · lab LAB-004214 · 2026-08-08 10:05
Peak creatinine this stay (mg/dL)	3.11	creatinine 3.11 mg/dL (peak this stay) · lab LAB-004216 · 2026-11-10 05:00
Peak / baseline peak / baseline	2.304	creatinine 3.11 mg/dL (peak this stay) · lab LAB-004216 · 2026-11-10 05:00 creatinine 1.35 mg/dL (pre-admission) · lab LAB-004214 · 2026-08-08 10:05
Largest creatinine rise between two values within 48 h (mg/dL) largest rise between two values within 48 hours	0.69	creatinine 2.42 · lab LAB-004215 · 2026-11-09 11:02 creatinine 3.11 · lab LAB-004216 · 2026-11-10 05:00
Longest run of urine output <0.5 mL/kg/h (hours; 6-hour blocks)	18	urine 189.8 mL / 6 h · vital VIT-012076 · 2026-11-09 22:02 urine 189.8 mL / 6 h · vital VIT-012077 · 2026-11-10 04:02 urine 189.8 mL / 6 h · vital VIT-012078 · 2026-11-10 10:02
Longest run of urine output <0.3 mL/kg/h (hours)	0	derived (no source row)
Longest run with no urine output (hours)	0	derived (no source row)

Rule trace (inputs, thresholds, outcome)

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=2.304, creat_rise_48h=0.69, t.ratio_s1=1.5, t.rise_abs=0.3, t.uo_s1_h=6, uo_hours_lt_0_5=18	true
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	anuria_hours=0, creat_peak=3.11, creat_ratio=2.304, meets_definition=True, rrt_started=False, t.anuria_h=12, t.ratio_s3=3.0, t.scr_s3=4.0, t.uo_s3_h=24, uo_hours_lt_0_3=0	false
derived: stage2	`creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false)`	creat_ratio=2.304, t.ratio_s2=2.0, t.uo_s2_h=12, uo_hours_lt_0_5=18	true
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	meets_definition=True, stage2=True, stage3=False	2
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.69, rrt_started=False, t.rise_abs=0.3	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	baseline_independent=True, stage=2	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2204); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: kidney function documentation
Encounter: ENC-00124   Patient: Jun Kestrel   To: Dr. Gideon Zeller

Clinical indicators from the health record:
- creatinine 1.35 mg/dL (pre-admission) (2026-08-08 10:05) [lab LAB-004214]
- creatinine 3.11 mg/dL (peak this stay) (2026-11-10 05:00) [lab LAB-004216]
- creatinine 2.42 (2026-11-09 11:02) [lab LAB-004215]
- urine 189.8 mL / 6 h (2026-11-09 22:02) [vital VIT-012076]
- urine 189.8 mL / 6 h (2026-11-10 04:02) [vital VIT-012077]
- urine 189.8 mL / 6 h (2026-11-10 10:02) [vital VIT-012078]

Question:
Based on your clinical judgement and the indicators above, can the kidney diagnosis being monitored and treated be further specified?

Response options (select one or write your own):
( ) Acute kidney injury (please specify stage, if known)
( ) 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.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2204	2026-11-14T20:57:25	system:llm system	`llm.call`	ENC-00124, ENC-00124.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt aa134379ab6c output 968dc8741b13 entry c784d5da3171
1378	2026-11-14T19:24:30	system:llm system	`llm.call`	ENC-00124, ENC-00124.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt aa134379ab6c output 968dc8741b13 entry 3dbed61f4f7a
636	2026-11-14T18:29:06	system:llm system	`llm.call`	ENC-00124, ENC-00124.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt aa134379ab6c output 968dc8741b13 entry 9066ecd1bc80