May 5, 2021

Primary Care and SBIRT?

Screening, Brief Intervention, & Referral to Treatment (SBIRT) Services


Detecting and implementing early intervention for your patients with non-dependent substance use is a critical part of primary care for many clinicians.  Using SBIRT can help you and your patients while getting reimbursed for these important services.

SBIRT is early intervention for individuals with non-dependent substance use to help before the individual requires more extensive or specialized treatment. This approach differs from specialized treatment for those with more severe substance misuse or a Substance Use Disorder (SUD). 

Early intervention is important and when medical records support reimbursement, you can bill for these services.

  • Medicare pays for medically reasonable and necessary SBIRT services in physicians’ offices and outpatient hospital settings.
  • Since January 1, 2020, CMS pays certified OTPs through bundled payments for OUD treatment services under Medicare Part B.
  • The patient’s medical records must support all Medicare claims.
  • States may cover SBIRT as a Medicaid state plan service.

Using SBIRT services can be manageable in primary care settings. You can systematically screen people who may not seek substance use help and offer access to SBIRT treatment services that:

  • Reduce health care costs;
  • Decrease drug and alcohol use severity;
  • Reduce risk of physical trauma; and
  • Reduce the percent of patients who go without specialized treatment.

SBIRT has 3 major components:

  • Screening;
  • Brief Intervention; and
  • Referral to Treatment.

1)  Screening

Screening is a quick, simple method of identifying patients who use substances at at-risk or hazardous levels and who may already have substance use-related disorders. The screening instrument provides specific information and feedback to the patient related to his or her substance use.

The typical screening process involves the use of a brief 1-3 question screen such as the National Institute on Alcohol Abuse and Alcoholism’s single question screen (see below under “Resources”). If a person screens positive, then a longer alcohol or drug use evaluation should be given using a standardized risk assessment tool such as AUDIT or ASSIST (references are under Resources below).

The screening and risk assessment instruments are easily administered and provide patient-reported information about substance use that any healthcare professional can easily score.

2)  Brief Intervention

Brief interventions are typically provided to patients with less severe alcohol or substance use problems who do not need a referral to additional treatment and services. In addition to behavioral health professionals, medical personnel (e.g., doctors, nurses, physician assistants, nurse practitioners) can conduct these interventions and need only minimal training. However, in cases of addiction, more intensive interventions may be needed.

  • How? Brief Intervention is a time-limited, patient-centered strategy that focuses on changing a patient’s behavior by increasing insight and awareness regarding substance use.
  • Depending on severity of use and risk for adverse consequences, a 5–10-minute discussion or a longer 20–30-minute discussion provides the patient with personalized feedback showing concern over drug and/or alcohol use.
  • The topics discussed can include how substances can interact with medications, cause or exacerbate health problems, and/or interfere with personal responsibilities.

3)  Referral to Treatment

In some cases, a more advanced treatment option is necessary and the patient is referred to a higher level of care. This care is often provided at specialized addiction treatment programs. The referral to treatment process consists of:

  • Helping patients access specialized treatment;
  • Selecting treatment facilities; and
  • Facilitating the navigation of any barriers such as cost of treatment or lack of transportation that would hinder them from receiving treatment in a specialty setting.

In order for this process to occur smoothly, primary care providers must initially establish and cultivate relationships with specialty providers, and then share pertinent patient information with the referral provider. Handling the referral process properly and ensuring that the patient receives the necessary care coordination and follow-up support services is critical to the treatment process and to facilitating and maintaining recovery.

Documenting SBIRT Services

Medicare provides documentation guidelines for the patient’s medical record.  The medical record for covered SBIRT services must:

  • Be complete and legible
  • Record start and stop times or total face-to-face time with the patient (because some SBIRT HCPCS codes are time-based)
  • Record the patient’s progress, response to changes in treatment, and diagnosis revision
  • Document the rationale for ordering diagnostic and other ancillary services or ensure it’s easily inferred

For each patient encounter, document:

  • Reason for encounter and relevant history
  • Appropriate health risk factors
  • Physical examination findings and prior diagnostic test results
  • Plan of care
  • Assessment, clinical impression, and diagnosis
  • Past and present diagnoses accessible for treating and consulting physicians
  • Date and legible provider identity
  • Signature on all services provided or ordered


CMS SBIRT Booklet 2021 (HCPCS codes, Telehealth & SBIRT and Bundled Payment Information)

Psychiatric Compliance - Short Online Course in Documentation & Coding

Screening: AUDIT Questionnaire


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