Substance Abuse Screening Guidelines

The NIH and SAMHSA recommend that physicians screen all patients over the age of 12 for potential substance abuse problems. Patients should be screened at every visit since substance use may change over time.

How To Do Substance Abuse Screening

  • Conduct a simple initial screening by asking about tobacco, alcohol, and drug use during the patient interview.Use a routine and non-judgemental approach when asking these questions.
  • Start with open-ended questions, "Tell me about your alcohol use?" instead of "Do you drink alcohol?" -- assuming that all patients consume some alcohol may yield more forthright answers. Prove responses by asking about frequency (how many days per week on average) and quantity (how many drinks on a typical day).
  • Alternatively, incorporate a short substance abuse screening instrument, like the 4-item CAGE or CAGE-AID (adapted version that also includes drug abuse), into a health status questionnaire that all patients complete before their appointment. When substance abuse is indicated, follow-up with additional interview questions to learn more.
  • Patients may be less honest about drug use, but many signs and symptoms of drug use can be identified through the physical exam, laboratory, or toxicological testing.
Related Resources: 
Description: 
This document provides a comprehensive collection of screening instruments and withdrawal assessments.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Resource Type: 
Commonly Used Forms: 
Physician stage in practice: 
Description: 
Chapter on substance abuse screening from a guide for primary care physicians. Includes choosing a screening test, screening techniques, and screening frequency.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
field_vote: 
Physician stage in practice: 
Description: 
Aids physicians in screening patients for opioid use disorders. Included are examples of screening instruments, recommendations of laboratory tests to complete, and medical disorders related to substance abuse.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
field_vote: 
Physician stage in practice: 

Commonly Used CPT and HCPCS Codes for Screening Potential Buprenorphine Patients

Description: 
The billing codes that can be used for screening and initial contact with your buprenorphine patients.

Current Procedural Terminology (CPT) Codes used for Buprenorphine Screening

The billing codes used for screening and initial contact with your buprenorphine patients. This information is based on a cost model developed in 2007 for buprenorphine treatment in California.

Service CPT/HCPCS Code
Alcohol and drug screening H0049
Brief Intervention H0050
Comprehensive Evaluation - New Patient 99215
Extended Office Visit - Established Patient 99215
Brief Office Visit - Established Patient 99211
TB Test - Skin 86580
Hepatitis Panel 80074
HIV Test 86703
Urinalysis - Drug Test 80100
Blood Test - Basic Metabolic Panel 80048
Blood Test - CBC 85025

(SAMHSA, 2004)