CDI Best Practices: Documentation Tips, Query Examples, and Real-World Scenarios

Master Clinical Documentation

With Real-World CDI Scenarios


Stay current with CDI best practices through clear documentation tips, compliant physician query examples, real-case scenarios, and annual ICD-10-CM updates from UASI’s CDI team.

CDI Scenarios

Welcome to UASI's CDI Central! Dive into the world of Clinical Documentation Improvement (CDI) with our collection of real-world scenarios and practical solutions. Whether you're new to CDI or a seasoned pro, our friendly and insightful content will help you tackle common challenges and enhance your documentation skills. From navigating complex cases to mastering best practices, we've got you covered. So, join us on this journey to improve patient care and streamline your documentation process, one scenario at a time!

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Child with cerebral palsy smiling during therapy activity with motor impairment and supportive care.

Cerebral Palsy: Documenting Motor Type, Severity, and Coding Impact

By Katie Curry • January 26, 2026
Support accurate cerebral palsy ICD-10-CM coding with CDI guidance on clinical indicators, documentation requirements, and physician query opportunities.
CDI Tip Title Graphic, mom and baby sleeping text reads

Apnea of Prematurity CDI Tip

By Katie Curry • January 13, 2026
Clarify apnea of prematurity clinical indicators, treatment considerations, and CDI coding guidance to support accurate neonatal documentation and query decisions.
MRI brain scans illustrating symptoms of PRES with title text overlay.

Symptoms of PRES: Diagnosis, Treatment, and ICD-10-CM Coding Guidance

December 9, 2025
Learn the symptoms of PRES, key treatment considerations, ICD-10-CM code I67.83, and documentation tips for CDI and accurate DRG assignment.
Microscopic immune cells interacting in cellular environment, illustrating immune effector activity

CDI Tip: ICANS Grading and Accurate Documentation

By Katie Curry • December 1, 2025
Understand ICANS documentation and ICD-10 coding with guidance on the ICANS grading system, ICE score, clinical indicators, and CAR T-cell neurotoxicity.
Fingerstick blood glucose test being performed, illustrating screening and monitoring practices for gestational diabetes.

Gestational Diabetes

By Katie Curry • November 3, 2025
Define gestational diabetes documentation requirements, key risk factors, and clinical details needed to support accurate ICD-10 coding, severity capture, and quality reporting.
Clinician pointing to anatomical kidney model illustrating acute kidney injury.

Acute Kidney Injury (AKI)

By Katie Curry • October 20, 2025
Learn how to identify, document, and code acute kidney injury (AKI), including diagnostic criteria, staging, ICD-10-CM guidance, and CDI query considerations.
Blurred hospital scene symbolizing CDI review of firearm injury intent reporting.

Reporting of Firearm Injury Intent

By Katie Curry • September 30, 2025
Learn how firearm injury intent is documented and reported in ICD-10-CM, including intent categories, external cause codes, and documentation considerations.
Title image for the ventricular standstill clinical documentation and coding overview

Ventricular Standstill

By Katie Curry • September 22, 2025
Learn how ventricular standstill is documented and coded, including clinical indicators, ICD-10-CM guidance, and common documentation considerations.
Title image for neurostorming (PSH) documentation and coding

CDI TIP: Neuro Storm

By Katie Curry • September 7, 2025
Learn how neurostorming, also known as paroxysmal sympathetic hyperactivity (PSH), is documented and coded using ICD-10-CM guidance.
Title photo of doctor for New ICD-10-CM code E11.A for type 2 diabetes mellitus in remission

New ICD-10-CM Code E11.A: Type II diabetes mellitus without complications in remission

By Katie Curry • August 7, 2025
FY 2026 ICD-10-CM coding guidance for new code E11.A, Type 2 diabetes mellitus without complications in remission, including documentation and query considerations.
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