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Dr. Naidu Clinical Sign-off Package

Compiled 2026-06-19 from GH issue #1376. This is what's queued for Dr. Shrikanth Naidu's review — the last clinical gate before the v6.2-flexible canary rollout (see v6_2-canary-rollout.md).

Status legend: [BUILT] = fix authored, PR ready to merge on his "yes" · [DEFERRED] = fix authored after his input.

TL;DR for the doctor (1-page summary)

Two [BUILT] items waiting only on your confirmation to merge their PRs:

  1. 10 etiology→ICD billable-unspecified-laterality code corrections (#1364) — replacement table below.
  2. 3 contraindications reclassified relative → absolute:
  3. ASA-IV on bilateral knee replacement
  4. Severe spinal instability on non-fusion lumbar surgery
  5. Severe cervical instability on non-fusion cervical surgery

Everything else (40+ items in 6 sections below) is deferred — fix is written after your call. Disposition rule per #1376: do NOT self-author clinical thresholds/codes.

If you can answer just the two [BUILT] items in under 15 minutes, that unblocks PR #1364 + the canary rollout. The rest is steady-state work and can wait for whatever your bandwidth allows.

The 2 [BUILT] items in detail

Item 1 — 10 etiology→ICD default corrections (#1364)

Current YAML defaults use billable unspecified-laterality codes across the catalog. The 10 corrections:

Etiology Old default New default Note
AVN hip M87.05 M87.059 unspecified-laterality billable
AVN knee M87.06 M87.063 tibia — M87.069 does NOT exist
AVN shoulder (was missing) M87.019
OA hip M16.1 M16.10
OA knee M17.1 M17.10
OA shoulder M19.01 M19.019
RA hip M05.751 M05.759
RA knee M05.76 M05.769
Post-traumatic hip M16.5 M16.50
Post-traumatic knee M17.3 M17.30

Q for Naidu: any objections to the 10 replacements above? Specifically the AVN knee → M87.063 (tibia) choice — should it be tibia or femoral side?

Item 2 — 3 contraindication reclassifications (#1364)

Contraindication Procedure Old New
ASA-IV bilateral_knee_replacement relative absolute
Severe spinal instability non-fusion lumbar (laminectomy, lumbar_decompression) relative absolute
Severe cervical instability non-fusion cervical (cervical_decompression) relative absolute

Q for Naidu: any of these wrong? Any other relative→absolute flips to bundle into the same PR while we're at it?

Deferred sections (priority-ranked — your bandwidth dictates order)

Section A — ICD-10 / CPT coding accuracy (5 items)

Beyond the 10 above: 1. 7 non-billable PARENT ICD candidates (C95.9, C91.0, C92.0 BMT; I21.0 CABG; H43.1 vitrectomy; H35.0 laser-photocoag; K08.1 dental) — verify billability + replacements 2. Breast-cancer laterality default — current C50.911 (right) is a generic; should resolve to captured side 3. Hair-transplant CPT — 15830 (panniculectomy) vs 15775/15776 4. lumbar_decompression CPT — 63047 (stenosis) vs 63030 (laminotomy + discectomy) 5. AVN knee tibia-vs-femoral (linked to BUILT item 1)

Section B — Pre-op screening-panel completeness (9 items)

Most important — pre-op screens that may be silently missing: - liver_transplant: add viral_screen_panel + cmv_screen + LFT - chemotherapy: add liver_function + viral_screen_panel - ivf: add viral_screen_panel (HIV/HepB/HepC) - knee/hip replacement: add dental_clearance (PJI risk)? - IVF cardiac cutoffs (ECG age>35 / echo age>40) - Dental-implant mandatory bloods — over-testing?

Section C — Validity windows & numeric thresholds (5 items)

  • Type & Crossmatch max_age_days (AABB ~72h)
  • Coagulation panel max_age_days (30 → 7-14?)
  • Arthroplasty peri-op HbA1c (>8%?), INR cutoffs, active-infection marker
  • Numeric interpretation_schema thresholds across all 18 SOPs (joint-space mm, malalignment°, Cobb°, …)
  • IVF TSH < 2.5 — soften or attribute to guideline?

Section D — Safety-gating rules (3 items, largest patient-facing rollout item)

  • Cauda equina gating combination + threshold (5 spine SOPs)
  • Cervical myelopathy / cord-compression — auto-gate vs require clinical signs
  • Open-fracture / compartment-syndrome gate + non-diagnostic emergency-care framing

Section E — Agent clinical-voice boundaries (6 items)

  • Agent must NEVER issue surgical-candidacy / indication verdicts — confirm
  • HbA1c provider-voiced general statement defensible?
  • ECG verbal self-report ever acceptable?
  • Document-grounded diagnosis relay ("the report indicates [C5-C6 stenosis / advanced OA]") — acceptable agent voice?
  • Severity-label-via-relay ("advanced", "severe", "Stage IIC aggressive")
  • 3 unattributed-agent-voice reframes (turn-4 of fracture_fixation / knee_arthroscopy / laminectomy) — confirm provider-attributed rewrites

Section F — Clinical plausibility & device sign-offs (5 items)

  • Plausibility pass on 15 fabricated_pending_ops procedure transcripts
  • v6.2 fixture realism — joint-space 2.1mm + osteophyte grade 3 for 62yo TKR — consistent?
  • Implant-lifespan figures — hip 15-20 vs knee 20-25 + non-promise phrasing
  • robotic_hip pre-op X-ray field set — post-op-only fields?
  • robotic variants — bmi/smoking/allergies dropped intentionally?

How to respond (3 light-touch options)

  1. Fast lane (5 min) — reply on the 2 [BUILT] items. Yes/no per line. Unblocks #1364 merge today.
  2. Medium lane (30 min) — go through Section B (pre-op screens) — second-most patient-impact category. Eng will draft fixes from your notes.
  3. Async lane — comment directly on GH #1376 line items at your pace. Eng watches the issue.

We'll close items off the checklist as you adjudicate them — no need to do it in any order.

What's NOT in scope for this signoff

  • Mock SOPs serving in prod — already accepted via the live-testing-is-signoff pattern per [[feedback_mock_sops_acceptable_in_prod]]. Don't relitigate; canary rollout proceeds with mock SOPs and Naidu ratifies via the live-test observation.
  • Price-policy gate (b) — already cleared via #1374 + #1375 (governed indicative ranges + bundle single-sourcing). Not on this page.
  • Stages 3-8 of the Product & Functional Blueprint V1 — separate product-strategy track; see docs/specs/product-blueprint-v6_2-gap-audit.md.
  • GH #1376 — the canonical tracking issue (always link here from Slack/email)
  • GH #1364 — the [BUILT] PR awaiting Naidu's call on the 2 items above
  • docs/runbook/v6_2-canary-rollout.md — what runs AFTER this signoff lands
  • [[feedback_mock_sops_acceptable_in_prod]] — the live-testing-is-signoff override