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-00162
Nadia Greaves: Chronic kidney disease
ENC-00162 · 65M · Hospital Medicine · admitted Mon Oct 26, 2026 09:04 AM · discharged Tue Nov 03, 2026 03:26 PM · attending Dr. Isaac Abernath · 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 37.2 (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)
- 690 Kidney and urinary tract infections without MCC → 690 Kidney and urinary tract infections without MCC
- Relative weight
- 0.8095 → 0.8095 (+0.0000)
- Codes before
- N39.0, E66.812, N18.4, N17.9, I50.9, E78.5, I10
- Codes after
- N39.0, E66.812, N17.9, I50.9, E78.5, I10, N18.32
All open gaps on this encounter together: MS-DRG 690 → 690 (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 1.96 -> eGFR 37
creatinine 2.09 -> eGFR 34
|
| Days between the earliest and latest pre-admission eGFR values | 237 |
creatinine 1.96 mg/dL -> eGFR 37 (CKD-EPI 2021)
creatinine 2.09 mg/dL -> eGFR 34 (CKD-EPI 2021)
|
| Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 37.2 |
creatinine 1.96 mg/dL -> eGFR 37 (CKD-EPI 2021)
|
| Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 34.5 |
creatinine 2.09 mg/dL -> eGFR 34 (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=237, t.chronic_days=90 | true |
| derived: staging_egfr | max(egfr_early, egfr_late) |
egfr_early=37.2, egfr_late=34.5 | 37.2 |
| derived: both_below_60 | egfr_early < t.g2 and egfr_late < t.g2 |
egfr_early=37.2, egfr_late=34.5, 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=37.2, 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=37.2, egfr_late=34.5, t.g2=60 | false |
| outcome: g1_g2 | staging_egfr >= t.g2 |
staging_egfr=37.2, 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 #2276); 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-00162 Patient: Nadia Greaves To: Dr. Isaac Abernath Clinical indicators from the health record: - Documented in the record: "CKD stage 4" [History and physical DOC-000546] - creatinine 1.96 -> eGFR 37 (2025-11-29 09:15) [lab LAB-005514] - creatinine 2.09 -> eGFR 34 (2026-07-24 10:05) [lab LAB-005515] 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
- Heart failure · Clinical judgement required Clinical judgement required: Only one acute indicator; acuity needs clinical judgement.
- Hyponatraemia · Specificity gap Criteria support Hyponatraemia (mild) (E87.1); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2276 | 2026-11-14T20:57:26 | system:llm system |
llm.call |
ENC-00162, ENC-00162.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 55a8c846a35e |
| 1450 | 2026-11-14T19:24:31 | system:llm system |
llm.call |
ENC-00162, ENC-00162.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 8193b898f1e8 |
| 708 | 2026-11-14T18:29:07 | system:llm system |
llm.call |
ENC-00162, ENC-00162.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt bd4fe48d41a5 output de54b895697d entry 641335b7dfd7 |