Criteria Library
Organization-defined clinical validation profiles are evaluated independently. They are not federal regulations or automatic coding authority.
5 clinical areas · 7 active profiles
Official coding policy
FY2026 ICD-10-CM Official Guidelines
April 1, 2026 update · 04/01/2026–09/30/2026
Clinical validation profiles
5 areas · 7 profiles
Independent criteria; KPC policy selects the controlling result
DRG calculation
MS-DRG v43 · FY2026
Runs after coder confirmation using the finalized code set
| Status | Clinical area | Clinical criteria and decision rule | Target codes | Rules | Version | Owner |
|---|---|---|---|---|---|---|
| Active | Malnutrition | Malnutrition — AND/ASPEN ASPEN/AND 2012 Six characteristics: energy intake, weight loss, fat loss, muscle loss, fluid accumulation, and grip strength. Decision: Two or more characteristics in the applicable acute or chronic illness context. Documentation: RD assessment plus treating-provider documentation before code assignment. | E43E44.0E44.1 | 6 | v1.3 07/02/2026 | HIM Coding Leadership |
| Active | Malnutrition | Malnutrition — GLIM GLIM 2019 Two-step framework: nutrition-risk screening followed by diagnostic assessment and severity grading. Decision: At least one phenotypic criterion plus at least one etiologic criterion. Documentation: Record the supporting phenotype and etiology; treating-provider documentation is required for code assignment. | E43E44.0E44.1 | 5 | v1.0 07/31/2026 | HIM Coding Leadership |
| Active | Sepsis | Sepsis — Sepsis-2 2001 SCCM/ESICM/ACCP/ATS/SIS Infection-associated systemic inflammatory response using the configured Sepsis-2 clinical profile. Decision: Suspected or confirmed infection plus two or more configured SIRS indicators. Documentation: Clinical indicators alone do not finalize coding; treating-provider documentation or CDI clarification is required. | A41.9R65.20R65.21 | 6 | v1.0 07/31/2026 | HIM Coding Leadership |
| Active | Sepsis | Sepsis — Sepsis-3 Sepsis-3 (2016) Life-threatening organ dysfunction caused by a dysregulated host response to infection. Decision: Suspected infection plus an acute SOFA increase of two or more. Documentation: Treating-provider diagnosis must be carried into inpatient documentation; otherwise route to CDI clarification. | A41.9R65.20R65.21 | 3 | v1.1 06/24/2026 | HIM Coding Leadership |
| Active | Acute Kidney Injury | Acute Kidney Injury KDIGO 2012 Acute change in kidney function assessed from creatinine and urine-output evidence. Decision: Creatinine 1.5x baseline within 7 days, a 0.3 mg/dL rise within 48 hours, or the configured urine-output criterion. Documentation: Treating-provider documentation is required before code assignment. | N17.9N17.0 | 3 | v1.2 06/24/2026 | HIM Coding Leadership |
| Active | Respiratory Failure | Acute Respiratory Failure Clinical indicators (P/F ratio, ABG) Hypoxemic or hypercapnic respiratory failure indicators with supporting oxygen or ventilatory requirements. Decision: Apply the KPC-approved ABG, oxygenation, baseline-change, and ventilatory-support thresholds. Documentation: Treating-provider documentation is required; clinical indicators without a diagnosis route to CDI clarification. | J96.00J96.01J96.02 | 5 | v1.0 06/24/2026 | HIM Coding Leadership |
| Active | Encephalopathy | Metabolic Encephalopathy Clinical indicators Acute altered mentation with an identified metabolic cause, distinguished from the patient's baseline. Decision: Acute mental-status change plus a supported metabolic etiology after configured exclusions. Documentation: Provider documentation of the diagnosis and etiology is required before code assignment. | G93.41 | 4 | v1.0 06/24/2026 | HIM Coding Leadership |
Consensus criteria such as Sepsis-2 and Sepsis-3 are separate from official ICD-10-CM coding rules. Profiles under the same clinical area are evaluated independently, and KPC policy determines which result drives an official flag. Every code still requires coder confirmation and applicable provider documentation.