DSM-5 criteria must be individualized and include specific signs and symptoms for each diagnosis. All must be determined as ‘Yes’ in order for medical necessity to be established. Only an LPHA may complete this form. When the beneficiary is receiving multiple levels of care, the LPHA would indicate all levels.

DSM-5 Substance Use Diagnosis *Required to include DSM-5 diagnosis on Service Request Form Examples ICD-10 Code *For billing purposes Severity Levels -Mild = Presence of 2-3 DSM criteria symptoms -Moderate = Presence of 4-5 DSM criteria symptoms -Severe = Presence of 6 or more DSM criteria symptoms Opioid Use Disorder

Per Title 22 CCR 51341.1 (b)(13): Intake includes the evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral, and substance use disorders; the diagnosis of substance use disorders, and the assessment of treatment needs. Gather the following information from Client. Client-perceived Problem?

The DSM-5 Checklist (DSM5) is an 11-item questionnaire that measures the degree (mild, moderate, severe) to which an individual meets diagnostic criteria for a substance use disorder. Each item is scored as yes or no in response to whether or not the statement describes the participant’s drinking or drug use over the past 12 months.

2025年2月21日 · This comprehensive chart shows screening and assessment tools for alcohol and drug misuse. Tools are categorized by substance type, audience for screening, and administrator. The chart also provides other assessment tools that may be useful for providers doing substance use work.

2022年7月15日 · This resource can also help assist states looking to facilitate continuity and consistency in substance use disorder (SUD) treatment delivery and coverage. Because it is paper-based, offered free to all clinicians , and can be used in many different clinical contexts, the Guide enhances the public utility of The ASAM Criteria’s ...

Client name: Date: Developed by Aaron Norton, LMHC, CAP, CRC Integrity Counseling, Inc. www.anorton.com DSM-5 Substance Use Disorder Assessment

sud diagnosis 11/07/2019 Diagnostic Criteria for Substance Use Disorder See DSM-5 for Criteria specific to the drugs identified as primary, secondary or tertiary.

A well-written Service Request Form will maximize the likelihood of timely service authorization approvals to facilitate the delivery of effective and appropriate substance use disorder (SUD) services.

Beneficiary must meet DSM-5 SUD diagnostic criteria and a “written basis” for the diagnosis must be documented in client’s record. For SUD diagnoses conducted by a therapist, PA, or NP, the physician must review the diagnosis and document approval by signing this form and the beneficiary’s treatment plan.