{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T08:25:04Z","timestamp":1794385504162,"version":"4.9.0"},"reference-count":7,"publisher":"American Health Information Management Association","issue":"2","license":[{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Adv Health Inf Sci Pract"],"published-print":{"date-parts":[[2026,9,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Preventive visits may be converted to problem-oriented evaluation and management (E\/M) services when documentation does not clearly support preventive service criteria, resulting in lost reimbursement despite appropriate care delivery. The objective of this study was to evaluate whether a diagnosis-triggered documentation template embedded within the electronic health record reduces conversion of preventive visit codes to problem-oriented E\/M codes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a 4-month observational evaluation in an academic family medicine clinic. A SmartText-based documentation template was triggered by the diagnosis of \u201cannual physical examination\u201d and inserted a standardized health care maintenance attestation into the clinical note. Encounters were classified as templated or nontemplated based on the presence of a SmartData Element. Preventive visit billing data were obtained from institutional reporting systems, and conversion rates were compared using a chi-square test, with effect size calculated using Cram\u00e9r\u2019s V.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 2310 preventive encounters, the template was used in 685 (29.7%). Overall, 37 visits (1.6%) were converted from preventive visit codes to problem-oriented E\/M codes. Conversion occurred in 4 templated visits (0.6%) compared with 33 nontemplated visits (2.0%). Template use was associated with a statistically significant reduction in conversion (\u03c7\n                      <jats:sup>2<\/jats:sup>\n                      = 6.40,\n                      <jats:italic>df<\/jats:italic>\n                      = 1,\n                      <jats:italic>P<\/jats:italic>\n                      = .011), with a small effect size (Cram\u00e9r\u2019s V = 0.053).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>A diagnosis-triggered documentation template was associated with reduced conversion of preventive visit codes to problem-oriented E\/M services. Relatively simple electronic health record (EHR) configuration changes may improve documentation consistency and influence downstream coding outcomes in primary care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.63116\/ah.000000005","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T16:36:57Z","timestamp":1788280617000},"source":"Crossref","is-referenced-by-count":0,"title":["Reducing Preventive-to-E\/M Code Conversion Using a Diagnosis-Triggered Documentation Template"],"prefix":"10.63116","volume":"2","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-9230-3950","authenticated-orcid":true,"given":"Joseph E.","family":"Capito","sequence":"first","affiliation":[{"name":"Department of Family Medicine, West Virginia University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathon T.","family":"Williamson","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, West Virginia University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelsey","family":"Samek","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, West Virginia University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kimberley","family":"Lanham","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, West Virginia University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erika","family":"Bodkins","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, West Virginia University"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"52461","reference":[{"issue":"7","key":"B1","series-title":"Cleve Clin J Med","first-page":"427","article-title":"Optimize your documentation to improve Medicare reimbursement","volume":"87","author":"Jaqua EE","year":"2020","unstructured":"Jaqua EE, Chi R, Labib W, Uribe M, Najarro J, Hanna M. Optimize your documentation to improve Medicare reimbursement. Cleve Clin J Med. 2020;87(7):427-434. doi:10.3949\/ccjm.87a.19116."},{"issue":"1","key":"B2","series-title":"JAMA Netw Open","first-page":"e2553157","article-title":"Role of chronic conditions in out-of-pocket costs for preventive care in the US","volume":"9","author":"Tran A","year":"2026","unstructured":"Tran A, Laporte A, Nauenberg E, Hoagland A. Role of chronic conditions in out-of-pocket costs for preventive care in the US. JAMA Netw Open. 2026;9(1):e2553157. doi:10.1001\/jamanetworkopen.2025.53157."},{"issue":"4","key":"B3","series-title":"Ann Intern Med","first-page":"301","article-title":"Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians","volume":"162","author":"Kuhn T","year":"2015","unstructured":"Kuhn T, Basch P, Barr M, Yackel T. Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162(4):301-303. doi:10.7326\/M14-2128."},{"issue":"5","key":"B4","series-title":"J Am Med Inform Assoc","first-page":"955","article-title":"Measures of electronic health record use in outpatient settings across vendors","volume":"28","author":"Baxter SL","year":"2021","unstructured":"Baxter SL, Apathy NC, Cross DA, Sinsky C, Hribar MR. Measures of electronic health record use in outpatient settings across vendors. J Am Med Inform Assoc. 2021;28(5):955-959. doi:10.1093\/jamia\/ocaa266."},{"issue":"3","key":"B5","series-title":"J Am Med Inform Assoc","first-page":"282","article-title":"Direct text entry in electronic progress notes: an evaluation of input errors","volume":"17","author":"Weir CR","year":"2010","unstructured":"Weir CR, Hicken BL, Nebeker JR, Campo R, Drews FA, LeBar B. Direct text entry in electronic progress notes: an evaluation of input errors. J Am Med Inform Assoc. 2010;17(3):282-286. doi:10.1136\/jamia.2009.000448."},{"issue":"20","key":"B6","series-title":"JAMA","first-page":"2335","article-title":"Copy-and-Paste","volume":"295","author":"Hirschtick RE.","year":"2006","unstructured":"Hirschtick RE. Copy-and-Paste. JAMA. 2006;295(20):2335\u20132336. doi:10.1001\/jama.295.20.2335."},{"issue":"1","key":"B7","series-title":"Appl Clin Inform","first-page":"12","article-title":"Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration","volume":"8","author":"Tsou AY","year":"2017","unstructured":"Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration. Appl Clin Inform. 2017;8(1):12\u201334. doi:10.4338\/ACI-2016-09-R-0150."}],"container-title":["Advances in Health Information Science and Practice"],"original-title":[],"link":[{"URL":"https:\/\/ahisp.kglmeridian.com\/view\/journals\/3995\/2\/2\/article-eah.000000005.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/ahisp.kglmeridian.com\/downloadpdf\/journals\/3995\/2\/2\/article-eah.000000005.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/ahisp.kglmeridian.com\/downloadpdf\/journals\/3995\/2\/2\/article-eah.000000005.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T07:45:56Z","timestamp":1794383156000},"score":1,"resource":{"primary":{"URL":"https:\/\/ahisp.kglmeridian.com\/view\/journals\/3995\/2\/2\/article-eah.000000005.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026]]},"references-count":7,"journal-issue":{"issue":"2"},"URL":"https:\/\/doi.org\/10.63116\/ah.000000005","relation":{},"ISSN":["3066-5825"],"issn-type":[{"value":"3066-5825","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026]]}}}