Addiction Medicine Patient Intake Software

Patient Intake in a Addiction Medicine Practice

Intake in addiction care does more than fill in a chart. It feeds the clinical assessment that decides the level of care, and that assessment is often what a payer reviews before it approves treatment. A typical packet starts with a validated screen such as the AUDIT or DAST. It then asks about each substance used, how it is used, past treatment, overdoses and current medications. Medical, mental health, housing and legal questions follow, since The ASAM Criteria look at the whole person. The patient signs the Part 2 consent and any release to a referring court or clinic. At check-in, staff confirm identity, scan the insurance card and open the visit. Addiction medicine patient intake software saves each answer as a structured field, so the clinician starts the assessment with the history already in front of them.

Why Is Patient Intake Different in Addiction Medicine?

The intake visit is also a billable service, and the rules are tight. A Medicare-enrolled OTP bills intake activities as an add-on, and only for patients starting treatment at that OTP. Medicaid programs often pay a separate assessment code under state Medicaid rules, with limits on how often it can be billed. Intake has to record what was done and by whom, or the visit can't be billed at all.

The questions are sensitive. Patients are asked about drug use, arrests, overdoses and sometimes trauma. Many fear the answers will reach an employer, a court or a family member. Clear consent screens, plain language and the option to finish forms in private all help patients answer honestly, and honest answers lead to the right level of care.

Speed matters for safety. A person in withdrawal or just out of a hospital stay may not come back if intake drags. Collecting history and consent before the visit, then confirming at check-in, lets the clinician start the medical exam sooner. For buprenorphine, that can mean the first dose happens at the first visit, not the second.

What Addiction Medicine Patient Intake Software Handles

OTP intake add-on (G2076)

G2076 covers intake activities, including the initial medical exam, a care plan and an optional evidence-based assessment. CMS limits it to new patients starting treatment at the OTP, so intake records whether the patient is new to that program. (Medicare Claims Processing Manual, Chapter 39: Opioid Treatment Programs (Rev. 13572, 2026))

Starting treatment by video at an OTP

Since 2025, an OTP may bill G2076 for starting methadone by audio-video when DEA and SAMHSA rules allow it. Buprenorphine can also be started this way. Intake notes the modality, and modifier 95 or 93 follows the claim. (Medicare Claims Processing Manual, Chapter 39: Opioid Treatment Programs (Rev. 13572, 2026))

Medicaid assessment code (H0001)

Washington Apple Health covers H0001 once per day for each new and returning client and does not allow updates to be billed as new assessments. Intake marks whether an assessment is new or an update. Other states set their own limits. (Washington Apple Health (Medicaid) Substance Use Disorder Billing Guide, October 2025)

Validated screens (AUDIT, DAST)

Medicare SBIRT codes G0396 and G0397 describe a structured assessment using tools such as the AUDIT or DAST. Intake forms can include these screens, and scores are saved for the clinician. (CMS MLN Booklet: Screening, Brief Intervention & Referral to Treatment (SBIRT) Services (MLN904084))

Multidimensional assessment (The ASAM Criteria)

The ASAM Criteria assess the patient across six dimensions to choose a level of care. Intake questions are grouped so they feed that assessment directly. (American Society of Addiction Medicine: About The ASAM Criteria)

Office-based first month (G2086)

For Medicare, G2086 covers at least 70 minutes of office-based SUD treatment in the first calendar month, including building the treatment plan. Intake time spent on the plan is logged so it counts toward that total. (CMS: Office-Based Substance Use Disorder (SUD) Treatment Billing)

How Does Addiction Medicine Patient Intake Software Work?

1. 1. Send forms before the visit

   Once the patient is registered, a secure link goes out by text or email. The patient completes screens, history and consents on their own phone, in private.

2. 2. Screen with validated tools

   The packet includes the screens the program uses, such as the AUDIT or DAST. Scores are saved as numbers, so the clinician can compare them later.

3. 3. Gather history by dimension

   Questions are grouped by the dimensions of the assessment, from withdrawal and medical needs to mental health and living situation. The answers line up with the level of care decision.

4. 4. Confirm at check-in

   Staff confirm identity, scan the insurance card and review any blank answers with the patient. The visit is marked as new or returning for billing.

5. 5. Hand results to the care team

   Answers post as structured fields to the clinical record and the patient's treatment record. The clinician sees the history before the exam starts.

Addiction Medicine Patient Intake Software vs. Generic Software

Who Uses It in a Addiction Medicine Practice

• Intake counselor: A complete history and screen scores before the assessment, so the session can focus on the patient.
• Medical director: Exam-ready charts at the first visit, with medication and overdose history up front.
• Billing team: Clear records of which intake or assessment service was done, by whom and how, ready for booking the next visits and for the claim.