Observational studyAdvances in health information science and practice2026
Reducing Preventive-to-E/M Code Conversion Using a Diagnosis-Triggered Documentation Template.
Observational study in Advances in health information science and practice, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
0 citing papers in PubMed.
No citing paper in PubMed yet.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Background: 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. Methods: We conducted a 4-month observational evaluation in an academic family medicine clinic. A SmartText-based documentation template was triggered by the diagnosis of "annual physical examination" 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 Cramér's V. Results: 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 (χ Conclusions: 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.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.