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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Lena Foxhall: Chronic kidney disease

ENC-00165 · 89M · Hospital Medicine · admitted Wed Nov 04, 2026 12:45 PM · discharged Thu Nov 12, 2026 10:04 AM · attending Dr. Jalen Carrow · resident Dr. Camila Oyelaran

Specificity gap Criteria met Open

Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 3a (N18.31).

Documented vs supported

Documented: “chronic kidney disease” · N18.9 Chronic kidney disease, unspecified
Criteria support: Chronic kidney disease stage 3a · N18.31 Chronic kidney disease, stage 3a
Outcome: Two eGFR values >=90 days apart, both below 60; staging value 56.7 (G3a)
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 -> N18.31
Secondary-diagnosis level: non-CC → non-CC
MS-DRG (illustrative): 195 Simple pneumonia and pleurisy without CC/MCC → 195 Simple pneumonia and pleurisy without CC/MCC
Relative weight: 0.6285 → 0.6285 (+0.0000)
Codes before: J18.9, N18.9, R09.02
Codes after: J18.9, R09.02, N18.31

All open gaps on this encounter together: MS-DRG 195 → 194 (RW +0.1774).

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

0.0 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 1.22 -> eGFR 57 · lab LAB-005641 · 2026-01-21 09:15 creatinine 1.35 -> eGFR 50 · lab LAB-005642 · 2026-07-17 10:05
Days between the earliest and latest pre-admission eGFR values	177	creatinine 1.22 mg/dL -> eGFR 57 (CKD-EPI 2021) · lab LAB-005641 · 2026-01-21 09:15 creatinine 1.35 mg/dL -> eGFR 50 (CKD-EPI 2021) · lab LAB-005642 · 2026-07-17 10:05
Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021)	56.7	creatinine 1.22 mg/dL -> eGFR 57 (CKD-EPI 2021) · lab LAB-005641 · 2026-01-21 09:15
Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021)	50.2	creatinine 1.35 mg/dL -> eGFR 50 (CKD-EPI 2021) · lab LAB-005642 · 2026-07-17 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=177, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=56.7, egfr_late=50.2	56.7
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=56.7, egfr_late=50.2, 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=56.7, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G3a
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=56.7, egfr_late=50.2, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=56.7, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G3a	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2281); 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-00165   Patient: Lena Foxhall   To: Dr. Jalen Carrow

Clinical indicators from the health record:
- Documented in the record: "chronic kidney disease" [History and physical DOC-000556]
- creatinine 1.22 -> eGFR 57 (2026-01-21 09:15) [lab LAB-005641]
- creatinine 1.35 -> eGFR 50 (2026-07-17 10:05) [lab LAB-005642]

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 3a (eGFR 45-59)
( ) Chronic kidney disease stage 3b (eGFR 30-44)
( ) 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

Hyponatraemia · Specificity gap Criteria support Hyponatraemia (profound) (E87.1); no corresponding diagnosis is documented.
Acute respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2281	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00165, ENC-00165.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 037b272ea91f
1455	2026-11-14T19:24:31	system:llm system	`llm.call`	ENC-00165, ENC-00165.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 1ff53b47f61b
713	2026-11-14T18:29:07	system:llm system	`llm.call`	ENC-00165, ENC-00165.ckd	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 8c76c4a57695