In simple words: This code covers a short session (5-14 minutes) where a healthcare professional uses a validated test to assess a patient's alcohol or drug (excluding tobacco) misuse and provides a brief counseling intervention.

This code represents a structured assessment for alcohol or substance (excluding tobacco) misuse using a validated instrument (e.g., AUDIT, DAST), followed by a brief intervention, all within a 5-14 minute timeframe. The assessment involves using a standardized tool to evaluate the patient's substance use, while the intervention comprises counseling and guidance on potential risks and steps towards behavioral change.

Example 1: A patient presents for a routine check-up and, through discussion, reveals occasional excessive alcohol consumption. The physician administers the AUDIT questionnaire, which indicates hazardous drinking. The physician then provides a brief intervention discussing the risks associated with this level of alcohol intake and suggests strategies for reducing consumption., A teenager admits to experimenting with marijuana. The healthcare provider uses the DAST-10 to assess the level of risk and provides a brief intervention discussing potential consequences and resources for support if needed. The total time spent on the assessment and intervention is 10 minutes., During a follow-up visit for hypertension management, a patient mentions increased stress and using prescription pain medication more frequently than prescribed.A healthcare provider performs a structured assessment using a validated opioid risk tool and a brief intervention focusing on safe medication practices and stress management techniques. This combined service takes 12 minutes.

Documentation should include the specific validated instrument used, the patient's score, the details of the brief intervention provided (topics discussed, advice given, and plan for follow-up), and the total time spent on both the assessment and intervention.