2025 CDI Week Q&A preview: Pediatrics and OB/GYN
As part of the fifteenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Rebecca Lewis, MSN, RN, CPN, NPD BC, CPC, CCDS, CDIP, CDI supervisor at Nemours Children's Hospital in Florida, answered these questions. Lewis is a member of the ACDIS Furthering Education Committee and the ACDIS Pediatric Networking Group. For questions about the committee or the Q&A, contact ACDIS Editor Jess Fluegel (jess.fluegel@hcpro.com).
Q: According to the 2025 CDI Week Industry Survey results, 46.25% of respondents reported their CDI teams review pediatric cases in either the inpatient or outpatient setting. How does your program review pediatric cases, and by whom? Has that structure evolved over time, and if so, how?
A: Our CDI program is based in a free-standing children’s hospital and is just over three years old. We began by focusing on less complex pediatric cases and gradually expanded our scope as the team gained confidence. All our CDI specialists come from pediatric nursing backgrounds, which has been instrumental in shaping and evolving our program. That clinical expertise has allowed us to build a strong foundation and adapt effectively to the unique needs of pediatric documentation.
Q: The remaining half of CDI programs do not yet review pediatric cases, though 7.48% have plans to in the next 12 months. What advice would you give those looking to expand into pediatric CDI? For those CDI programs with a pediatric population at their organization but who have yet to make the plunge, what do you think are the impediments in their way?
A: For those expanding into pediatric CDI, it’s essential to understand the coding nuances around common pediatric diagnoses like respiratory failure, congenital heart defects, and neuromuscular disorders. Just as critical is partnering with pediatric clinicians to grasp how these conditions uniquely present and progress in children. One major barrier for many programs is the lack of pediatric-specific clinical knowledge; ICD-10 simply wasn’t built with pediatrics in mind. Differentiating between congenital and acquired conditions and understanding their implications takes time and a strong clinical foundation. Transparency with providers and a collaborative, team-based approach is key to building trust and driving success. Start small, stay curious, and grow with your team’s confidence and experience.
Q: The most common pediatric setting/service line reviewed by CDI teams was general pediatric inpatient admissions (chosen by 85.45% of respondents), followed by PICU (79.85%) and NICU (73.51%). Which service lines does your CDI program look at for pediatric cases, and how was that decision made? If you review more than one pediatric setting, what differences are there between them when it comes to chart review, querying, provider engagement, etc.? Does your program have any plans to expand into other pediatric settings/service lines?
A: Our CDI program reviews all inpatient pediatric service lines. As each area was brought into scope, we ensured the CDI team and providers received thorough education, with ongoing feedback to refine workflows and clarify expectations. Each setting presents its own unique challenges, so it’s important to understand how providers perceive CDI queries and who on the care team is responsible for addressing them. Tailoring feedback to their specific patient population and documentation practices has helped foster stronger engagement.
When issues arise from a coding or denials standpoint, we bring those back to the providers for input, which supports continuous improvement at the department level. This collaborative approach has been key to our success across diverse inpatient settings. Looking ahead, we plan to expand into the pediatric ambulatory setting within the next year and are currently evaluating whether to begin with primary care or specialty care.
Q: APR-DRG accuracy was the top focus for pediatric reviews (78.36%), followed by ICD-10 coding accuracy (76.12%) and quality measures (53.36%). Risk adjustment was also a top focus, chosen by 39.55% of respondents. What are your top focuses when conducting a pediatric review, and how are those focuses decided by your department? Has it evolved over time, and if so, how and why?
A: Our primary focus during pediatric reviews is ICD-10 coding accuracy, particularly to ensure the appropriate APR-DRG is assigned and that the severity of illness and risk of mortality accurately reflect the care provided. This directly ties into quality metrics and risk adjustment, which are essential in demonstrating the complexity and outcomes of pediatric care. As an APR-DRG–driven organization, we initially placed less emphasis on CC and MCC capture, but that has evolved as we’ve encountered more commercial payers. Now, we ensure that when clinically appropriate, these conditions are clearly documented and well supported to meet broader coding and reimbursement requirements.
Q: When respondents were asked how they track their pediatric CDI impact, the most common answer was using a modified version of adult-specific CDI software (37.69%). Almost 24% of respondents said they don’t currently have a way to track their impact. Does your program track its impact, and if so, how? Do you have any advice for those looking to start? Why do you think this might be a struggle for CDI departments?
A: Yes, our program does track its pediatric CDI impact, though much of the tracking is done manually. We collaborate closely with our revenue integrity team to ensure the accuracy and reliability of the data we collect. Additionally, we leverage resources from the Children's Hospital Association to support our efforts from a quality improvement standpoint. For those looking to start, I recommend partnering with your administrative teams to identify the specific impacts they want to measure and exploring available technologies and internal resources to support that tracking. The struggle many CDI departments face in pediatric reviews stems from the unique nature of the population, which often renders standard adult-focused CDI and coding tools less applicable—many of our resources have had to be developed internally to meet these needs.
Q: The majority of respondents chose respiratory failure as their top queried diagnosis during pediatric reviews (66.79%). Respiratory distress syndrome was in second place (53.36%), and sepsis was in third place (47.01%). Why do you think these three might be the most common diagnoses queried for the pediatric population? Does this reflect the trends at your organization? What strategies has your CDI program implemented to improve accurate documentation of these diagnoses?
A: Respiratory failure, respiratory distress syndrome, and sepsis are frequently queried in pediatric CDI because they all lack universally accepted clinical definitions, leading to variability in interpretation. Criteria for these diagnoses can differ between providers, departments, and even specialties, depending on clinical background and training. This inconsistency makes documentation challenging and contributes to frequent queries. We experience this same trend in our organization and regularly query for clarification on these conditions. To improve documentation, we focus on understanding the criteria our providers use and encourage them to include that explicitly in their notes. Additionally, we educate our providers on the importance of clinically validating their diagnoses, especially when dealing with conditions that lack well-defined standards.