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.

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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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Diabetic Nephropathy ICD-10 CDI Tips

When to Query for Diabetic Nephropathy

By Alyce Reavis, RN, MSN, CCDS, CCS • July 20, 2026
Learn how UASI's CDI tips help link diabetes with CKD using diabetic nephropathy ICD 10 codes for accurate, complete clinical documentation.
Hospital room with several empty hospital beds

When to Query for Hypertensive Crisis: CDI Documentation Tips

By Alyce Reavis, RN, MSN, CCDS, CCS • July 20, 2026
Improve coding accuracy with UASI's CDI tips for differentiating hypertension urgency ICD-10 coding from hypertensive emergency to support accurate MS-DRG and severity capture.
Title graphic with brain, When to Query for Hepatic Encephalopathy

When to Query for Hepatic Encephalopathy

By Alyce Reavis, RN, MSN, CCDS, CCS • July 7, 2026
Learn how hepatic encephalopathy ICD-10 coding works, what clinical indicators trigger a CDI query, and documentation requirements for accurate code capture.
Mother carrying newborn baby

Postpartum Hemorrhage: Documentation and Coding Considerations

By Alyce Reavis, RN,MSN,CCDS,CCS • June 23, 2026
Review clinical indicators, ICD-10-CM coding, CDI considerations, and query opportunities for postpartum hemorrhage documentation.
doctors hovering over operating table

Non-Infectious SIRS: Documentation and Coding Considerations

By Alyce Reavis, RN,MSN,CCDS,CCS • April 16, 2026
Review clinical indicators, coding rules, and documentation considerations for non-infectious SIRS, including R65.10 vs R65.11 and query guidance.
Graphic title, person sitting down and holding both hands to chest

When to Query for Acute Respiratory Failure with Hypoxia (J96.01)

By Alyce Reavis, RN,MSN,CCDS,CCS • April 15, 2026
Learn when to code acute respiratory failure with hypoxia (J96.01), including clinical indicators, documentation tips, and CDI query opportunities.
Graphic image for ICD-10-PCS Changes for April 1, FY 2026, doctor pointing to computer

ICD-10-CM and ICD-10-PCS Changes for April 1, FY 2026

By Alyce Reavis, RN,MSN,CCDS,CCS • March 16, 2026
Review key ICD-10-CM updates effective April 1, 2026 including Parkinson’s disease indexing changes, respiratory failure coding revisions, and neuroendocrine tumor classification updates.
Child with cerebral palsy smiling during therapy activity with motor impairment and supportive care.

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

By Alyce Reavis, RN, MSN, CCDS, CCS • 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 Alyce Reavis, RN,MSN,CCDS,CCS • 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.
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