2025 CPT code 99408
(Active) Effective Date: N/A Revision Date: N/A Preventive Medicine Services - Substance Abuse Screening and Intervention Evaluation and Management > Preventive Medicine Services Feed
Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes.
Modifier 25 may be appended if a significant, separately identifiable E/M service is also provided on the same day. Modifier 33 (Preventive Services) may also apply.
Medical necessity is established when a patient presents with symptoms or behaviors suggestive of alcohol or other substance abuse, or when routine screening reveals potential substance abuse problems.The SBI addresses immediate risks and facilitates engagement in further treatment or support, preventing potential negative consequences.
The clinician's responsibility includes administering a validated screening instrument (e.g., AUDIT, DAST), interpreting the results, and conducting a brief intervention based on the assessment.This involves motivational interviewing, discussing risks, and collaboratively developing a plan for behavior change.
In simple words: The doctor or healthcare provider uses a special test to check for alcohol or drug problems (not including tobacco).If there's a problem, they'll spend 15-30 minutes talking to you about it, helping you understand the risks, and making a plan to help you reduce or stop substance use.
This CPT code encompasses a structured screening for alcohol or other substance (excluding tobacco) abuse, utilizing validated instruments like the Alcohol Use Disorders Identification Test (AUDIT) or the Drug Abuse Screening Test (DAST).Following the screening, a brief intervention (SBI) is conducted, lasting 15-30 minutes. The SBI involves discussing the negative health and social consequences of substance abuse, assessing the frequency and quantity of substance use, outlining behavior change strategies, and developing plans for subsequent steps.Documentation must include the specific screening instrument used and a detailed record of the intervention provided.
Example 1: A patient presents for an annual physical.During the preventive medicine visit, the provider administers the AUDIT, revealing a concerning score.A subsequent 20-minute SBI is conducted, addressing risk factors and collaboratively creating a plan to reduce alcohol consumption., A patient reports feeling overwhelmed by stress and begins self-medicating with alcohol. The provider utilizes the DAST, revealing a high risk for substance abuse. Following the screening, a 25-minute SBI session is held, and the patient is referred to a substance abuse specialist., A patient admitted to hospital for another condition admits to using recreational drugs.The provider performs a brief DAST screen and SBI that highlights the potential for harm and motivates them to utilize the hospital's resources to facilitate substance abuse cessation.
* Documentation of the screening instrument used (e.g., AUDIT, DAST) and the raw scores.* Detailed notes on the brief intervention provided, including discussion points, patient responses, and the collaboratively developed plan for behavior change.* Time spent on the screening and intervention (must be at least 15 minutes to report this code).
** The use of validated screening instruments is crucial for accurate coding.Documentation must clearly support the medical necessity of the services rendered.
- Revenue Code: M5D (SPECIALIST - OTHER)
- RVU: Information not available in provided sources.RVUs vary based on geographic location and payer.
- Global Days: Not applicable. This is not a surgical procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Information not available in provided sources.Consult fee schedules from relevant payers.
- Specialties:Primary Care, Addiction Medicine, Psychiatry, Internal Medicine, Family Medicine
- Place of Service:Office, Outpatient Hospital, Urgent Care Facility, Federally Qualified Health Center, Rural Health Clinic,Telehealth (with appropriate modifiers)