What CPT codes are used for substance use disorder evaluations?

Initial evaluation uses 90791 (diagnostic evaluation) or 90792 (with medical services). SBIRT (Screening, Brief Intervention, Referral to Treatment) uses 99408-99409 (15-30 min alcohol/substance screening and intervention). Medication management for addiction uses standard E/M codes. Document complexity for code selection. G-codes available for certain MAT services.

What DSM-5 documentation is required for substance use disorder diagnosis?

Document: specific criteria met from DSM-5 (≥2 of 11 criteria within 12 months), substance involved, severity (mild 2-3 criteria, moderate 4-5, severe ≥6), specifiers (in early/sustained remission, on maintenance therapy, in controlled environment). Include functional impairment in social, occupational, or physical domains.

How should withdrawal risk be documented?

Document: history of prior withdrawal episodes, severity of prior withdrawal (seizures, delirium tremens, hallucinations), current dependence pattern, time since last use, current vital signs, and CIWA or COWS scores if applicable. Document medical conditions affecting withdrawal risk. This determines level of care needed for safe detoxification.

What documentation supports medication-assisted treatment (MAT)?

Document: diagnosis of opioid use disorder with DSM-5 criteria, assessment of appropriateness for MAT, informed consent discussion, pregnancy status, monitoring plan (drug screens, diversion assessment), and rationale for medication choice (buprenorphine, naltrexone, methadone). Include evaluation for co-occurring psychiatric conditions that affect MAT selection.

How do I document level of care determination?

Document: ASAM criteria assessment including acute intoxication/withdrawal risk, biomedical conditions, emotional/behavioral conditions, treatment acceptance, relapse potential, and recovery environment. Document why recommended level of care (outpatient, IOP, PHP, residential, detox) is appropriate. Include barriers to higher/lower level of care if applicable.

Substance Abuse Assessment Template - Addiction Evaluation

Psychiatry — Substance Abuse Assessment Template

Psychiatry Psychiatry Updated: 11/7/2025

The Substance Abuse Assessment Template is designed for psychiatrists, addiction medicine specialists, and mental health providers conducting comprehensive evaluations for substance use disorders. This detailed template documents substance use history, patterns of use, consequences, withdrawal symptoms, treatment history, and treatment planning. The template follows DSM-5 diagnostic criteria for substance use disorders and includes sections for comprehensive substance use history including all substances used, patterns of use including frequency and quantity, route of administration, tolerance and withdrawal symptoms, functional impairment assessment, legal and social consequences, previous treatment attempts and outcomes, readiness for change assessment, physical examination findings, laboratory testing including drug screens, diagnostic formulation, treatment recommendations including level of care determination, and follow-up planning. This template ensures thorough substance use evaluation, supports accurate diagnosis, facilitates appropriate treatment planning, and improves patient outcomes through comprehensive assessment. Ideal for addiction medicine practices, psychiatric practices managing substance use, primary care practices with addiction services, and treatment centers conducting intake evaluations.

Visit Information

Visit type: Initial substance abuse evaluation / Follow-up
Referral source: [If applicable]

Chief Complaint

[Patient's stated reason for evaluation]

Substance Use History

Primary Substance

Substance: [Alcohol, opioids, stimulants, cannabis, etc.]
Age of first use: [Age]
Pattern: [Frequency, quantity, route]
Last use: [Date]
Longest period of abstinence: [Duration]

Other Substances

[List all substances used with patterns]

Current Use

Frequency: [Daily, weekly, etc.]
Quantity: [Amount per use]
Route: [Oral, IV, inhaled, etc.]
Tolerance: Present / Absent
Withdrawal: Experienced / Not experienced

Consequences

Legal: [DUIs, arrests, etc.]
Occupational: [Job loss, performance issues]
Relationship: [Family, social problems]
Medical: [Health problems]
Financial: [Financial problems]

Withdrawal History

Symptoms experienced: [Tremors, seizures, hallucinations, etc.]
Severity: [Mild, moderate, severe]
Treatment: [Detox, medications, etc.]

Treatment History

Previous treatment: [Detox, rehab, IOP, outpatient, AA/NA, MAT]
Outcomes: [What worked, what didn't]
Current treatment: [If applicable]

Readiness for Change

Stage: Pre-contemplation / Contemplation / Preparation / Action / Maintenance
Motivation: [Level and factors]

Physical Examination

Vital signs: BP, HR, RR, Temp
General: Appearance, signs of intoxication or withdrawal
Cardiovascular: [If relevant]
Respiratory: [If relevant]
Neurological: [If relevant]
Skin: [Track marks, etc. if relevant]

Laboratory

Drug screen: [Results if obtained]
Liver function: [If indicated]
Other: [As indicated]

Assessment

1) [Substance] Use Disorder, [Mild / Moderate / Severe]

Withdrawal: Present / Absent
Other specifiers: [In remission, etc.]

2) [Other psychiatric diagnoses if applicable]

Plan

1) Treatment recommendations:

Level of care: [Detox, residential, IOP, outpatient]
Medications: [MAT if indicated]
Therapy: [Individual, group, etc.]
Support groups: [AA, NA, etc.]

2) Safety planning: [If indicated]
3) Follow-up: [Treatment plan, next appointment]

Patient Education

Treatment options discussed. Patient verbalized understanding. Treatment plan established.