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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Ximena Hartwell: Pressure injury

ENC-00166 · 80M · Pulmonology · admitted Tue Nov 10, 2026 12:02 PM · in hospital · attending Dr. Wes Merriweather · resident Dr. Priya Thorne

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

Documented “sacral pressure ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, stage 3 (L89.153).

Documented vs supported

Documented: “sacral pressure ulcer” · L89.159 Pressure ulcer of sacral region, unspecified stage
Criteria support: Pressure injury of sacral region, stage 3 · L89.153 Pressure ulcer of sacral region, stage 3
Outcome: Wound nurse documents stage 3, sacral
Rule: Pressure injury stage (sacral region) v2026.11-1
Published source: NPIAP Pressure Injury Stages (revised staging system) (2016), Stage 1-4, unstageable, deep tissue pressure injury definitions · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: L89.159 -> L89.153
Secondary-diagnosis level: non-CC → MCC
MS-DRG (illustrative): 192 Chronic obstructive pulmonary disease without CC/MCC → 190 Chronic obstructive pulmonary disease with MCC
Relative weight: 0.6420 → 1.1077 (+0.4657)
Codes before: J44.1, L89.159, K21.9, E78.5
Codes after: J44.1, K21.9, E78.5, L89.153

All open gaps on this encounter together: MS-DRG 192 → 190 (RW +0.4657).

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

1.0 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
Stage quoted from the wound-care note	3	“Stage: 3” · Wound care note DOC-000560, p. 1, line 5 · quoted span verified Show the quote in the note WOUND CARE NOTE Patient: Ximena Hartwell MRN: MRN24415470 Location: sacrum Stage: 3 (NPIAP) Description: full-thickness skin loss, adipose visible, no tendon or bone. Size: 2.0 x 3.2 x 0.2 cm. Plan: offloading every 2 hours, foam dressing, nut …
Site quoted from the wound-care note	sacral	“Location: sacrum” · Wound care note DOC-000560, p. 1, line 4 · quoted span verified Show the quote in the note WOUND CARE NOTE Patient: Ximena Hartwell MRN: MRN24415470 Location: sacrum Stage: 3 (NPIAP) Description: full-thickness skin loss, adipose visible, no tendon or bone. Size: 2.0 x 3.2 x 0.2 cm. Plan: offloading every 2 hours, foam dres …

Rule trace (inputs, thresholds, outcome)

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=sacral	true
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=3	false
outcome: other_site	`wound_site != 'sacral'`	wound_site=sacral	false
outcome: stage1	`sacral and wound_stage == '1'`	sacral=True, wound_stage=3	false
outcome: stage2	`sacral and wound_stage == '2'`	sacral=True, wound_stage=3	false
outcome: stage3	`sacral and wound_stage == '3'`	sacral=True, wound_stage=3	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2286); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: skin integrity documentation
Encounter: ENC-00166   Patient: Ximena Hartwell   To: Dr. Wes Merriweather

Clinical indicators from the health record:
- Documented in the record: "sacral pressure ulcer" [Progress note DOC-000562]
- "Stage: 3" (2026-11-11 13:02) [Wound care note DOC-000560, p. 1, line 5]
- "Location: sacrum" (2026-11-11 13:02) [Wound care note DOC-000560, p. 1, line 4]

Question:
The wound-care documentation above is part of this encounter. Based on your clinical judgement, can a related diagnosis be documented, including site and stage?

Response options (select one or write your own):
( ) Pressure ulcer of sacral region, stage 3
( ) 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 kidney injury · Clinical judgement required Clinical judgement required: AKI criteria met only against a presumed baseline (no pre-admission creatinine on file).
Obesity · Specificity gap Criteria support Obesity, class 3 (E66.813); no corresponding diagnosis is documented.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2286	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00166, ENC-00166.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 94204f2cd745 output 29146ed5aa61 entry c82be367e49b
1460	2026-11-14T19:24:31	system:llm system	`llm.call`	ENC-00166, ENC-00166.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 94204f2cd745 output 29146ed5aa61 entry 6fbd1cd25a39
718	2026-11-14T18:29:07	system:llm system	`llm.call`	ENC-00166, ENC-00166.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 94204f2cd745 output 29146ed5aa61 entry a64153581072