Nephrology Ambient Scribe for CKD and G2211 Notes

Specialty Documentation Architecture

Clinical documentation in Nephrology rarely concerns a single visit. A CKD encounter folds months of creatinine values, albuminuria measurements, potassium excursions, and medication adjustments into one assessment. The note has to show not only what happened today but how today fits a trajectory the nephrologist has been steering for years.

Merry AI listens to the encounter ambiently and separates the speakers: the patient describing fatigue or ankle edema, a spouse recounting missed phosphate binder doses, and the clinician reasoning aloud about potassium binders or SGLT2 inhibitor continuation. Each statement is attributed to its source, so caregiver history never blends into patient-reported symptoms, and the Subjective section reads the way a careful fellow would write it.

Reading the Lab Panel Without Tab Bouncing

With clinician-granted read access, the Chrome Extension reads the lab panel already rendered in the EHR browser window. It parses visible eGFR results with their collection dates, along with urine albumin-to-creatinine ratio, and assembles a dated trajectory. Nothing is written to the lab module; the extension observes the page the clinician has open and drafts from it. Access is scoped per EHR and can be revoked at any time.

A typical drafted trajectory reads: eGFR 32 (01/2025), 28 (07/2025), 24 (01/2026), with UACR persistently above 300 mg/g. From those values the system proposes a KDIGO classification, here G4 A3, and flags the rate of decline so the clinician can confirm or correct it before anything enters the note.

KDIGO Staging and the Longitudinal Assessment

KDIGO classification depends on two axes. The G category follows eGFR: G1 at 90 or above, G2 from 60 to 89, G3a from 45 to 59, G3b from 30 to 44, G4 from 15 to 29, and G5 below 15 or on dialysis. The A category follows albuminuria: A1 below 30 mg/g, A2 from 30 to 300, and A3 above 300. Merry AI drafts both categories and cites the values behind them.

Staging alone does not carry an assessment. The drafted plan ties the trajectory to decisions: RAAS blockade at maximally tolerated dose, SGLT2 inhibitor continuation, finerenone consideration in diabetic kidney disease, anemia and mineral bone disorder monitoring, and a dated next-lab order such as BMP, CBC, phosphorus, PTH, and UACR on 12/08/2026. That dated plan is what makes ongoing management visible to a reviewer.

Dialysis Access and Transplant Coordination

For patients approaching kidney replacement therapy, the note captures the coordinated access plan in plain clinical language: vein mapping status, vascular surgery referral for arteriovenous fistula, peritoneal dialysis candidacy, and transplant evaluation referral. When the clinician discusses timing aloud, such as initiating hemodialysis when eGFR falls below 15 with uremic symptoms, Merry AI places that reasoning in the Plan rather than burying it in narrative.

G2211 Evidence and Billing Defense

CMS describes HCPCS G2211 as visit complexity inherent to care that serves as the continuing focal point for all needed services, or that is part of ongoing care for a single, serious or complex condition. Advanced CKD fits the second clause when the nephrologist holds the longitudinal relationship. The add-on applies with office visits 99202 through 99215 and, from 2026, home or residence visits 99341 through 99350.

Every G2211 attestation should state four things: the ongoing CKD management role, the eGFR trend, the KDIGO stage, and the dated next-lab plan. Merry AI drafts each as a discrete line, and the attestation is never inserted without a clinician click and review. Diagnosis specificity, such as N18.4 for stage 4 CKD or E11.22 for type 2 diabetes with diabetic CKD, can be verified against https://www.cms.gov/medicare/coding-billing/icd-10-codes.

Modifier 25 and Same-Day Services

Modifier 25 deserves particular care. Under CMS Change Request 13705, effective January 1, 2025, G2211 remains payable with a modifier 25 E/M only when the same-day service is an annual wellness visit, vaccine administration, or a qualifying Part B preventive service. A same-day minor procedure still blocks the add-on. Merry AI keeps the longitudinal CKD narrative separate from acute issues such as hyperkalemia management, so each element stands on its own.

Integration, Privacy, and Governance

The Chrome Extension writes into the active Assessment field, whether a textarea or a contenteditable editor, and declines to write into Orders, Problem List, or patient instruction fields. There is no API contract to negotiate and no interface engine to configure.

Protected health information is processed in memory and shredded at session close, under an executed Business Associate Agreement. Chart-only assessment text is kept distinct from patient-facing summaries, so California AB 3030 disclosure language can be appended where patient communications require it. Every inserted attestation is logged with the confirming clinician, consistent with SB 1120 and emerging Texas AI oversight expectations.

Specialty prompt packs for CKD clinic visits, monthly dialysis rounding, and transplant follow-up are available at https://templates.scribing.io.