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Docusistant™ — SUD Assessment + Psychotherapy (H0001 + 90837)
DOCUSISTANT™ — Substance Use
Administrative
Date of service
Clinician (name + credentials)
Place of service
11 — Office
02 — Telehealth
12 — Home
Start / End
to
Total minutes
Diagnosis (ICD-10 F10–F19)
Category
Specific diagnosis
Assessment
When did symptoms begin?
Within the past month
1–3 months ago
3–6 months ago
6–12 months ago
Over a year ago
Chronic / long-term
Other (specify)
Triggers / Aggravating factors
Social stressors
Family conflict
Financial pressure
Legal problems
Peer influence
Environmental cues
Other
Helpful coping strategies
Exercise / physical activity
Mindfulness / relaxation
Social support
Spiritual or faith-based activities
Self-help meetings (AA/NA/SMART)
Healthy routine / structure
Other
Risk assessment summary
Denies SI/HI; no acute risk
Passive suicidal ideation; no plan or intent
Active suicidal ideation; no plan
Active suicidal ideation with plan — safety plan created
Substance relapse risk elevated; no immediate danger
Substance relapse risk high; safety monitoring required
Other (specify)
ASAM Snapshot / Stage of Change
ASAM Dimensions 1–3
Acute Intox/Withdrawal — none
mild
moderate
severe
Biomedical — none
mild
moderate
severe
Emotional/Behavioral — none
mild
moderate
severe
Stage of change
precontemplation
contemplation
preparation
action
maintenance
Psychotherapy (90837)
Techniques used
Motivational Interviewing
CBT for SUD
Relapse Prevention
Client presentation
Engagement:
fully engaged
partially engaged
minimally engaged
resistant or guarded
distracted or disengaged
Affect:
congruent
restricted
flat
labile
incongruent
Demeanor:
calm and cooperative
anxious
dysphoric
irritable
tearful
euthymic
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Generated SUD Note