Which Code Bills a Substance Abuse Evaluation: H0001 or 90791?

No single code works for every payer, so the payer's code list decides which one you bill.

Medicare pays the psychiatric diagnostic evaluation 90791 and its version with medical services, 90792. Both carry status A in the CY2026 fee schedule file, which means they're paid separately under the physician fee schedule if covered (CMS RVU26D status codes).

For a structured assessment with brief intervention, Medicare uses the SBIRT codes G2011 (5 to 14 minutes), G0396 (15 to 30 minutes) and G0397 (greater than 30 minutes) (CMS MLN904084, p. 5).

Medicaid works differently. CMS says certain H codes are used by state Medicaid agencies that state law requires to keep separate codes for mental health services such as alcohol and drug treatment (CMS HCPCS Level II coding procedures, p. 6). Programs that use them can list H0001, the alcohol and/or drug assessment.

Next step: map each payer you bill to the evaluation code its fee schedule lists before the next intake is booked.

Medicare doesn't pay H0001, H0002 or H0004 because CMS lists each of them as not payable by Medicare.

The October 2026 HCPCS file gives H0001, H0002, H0004, H0005, H0031, H0049, H0050 and T1007 coverage code I, which means not payable by Medicare (CMS HCPCS quarterly update, October 2026 file). The CY2026 fee schedule file gives the same eight codes status I, not valid for Medicare purposes, and says Medicare uses another code for these services (RVU26D status I definition).

So an SUD intake sent to Medicare on H0001 goes unpaid. The same evaluation billed as 90791 has a CY2026 national non-facility amount of $173.35 before locality adjustment. That's 5.19 total RVUs times the $33.4009 conversion factor in the CMS file (CMS RVU26D, 90791 row).

Watch patients who have both Medicare and Medicaid. Their Medicare claim needs a code Medicare pays, even when the intake form was built around the Medicaid code set. For Medicare Advantage patients, check the plan's billing policy before you pick the code.

If your program bills the same intake to several payers, see how we handle substance use disorder billing across payers.

Next step: pull last quarter's Medicare and dual-eligible claims that carried an H code and check how each one was paid.

H0001 is the alcohol and/or drug assessment, H0002 is a screening to decide admission to a treatment program and H0031 is a mental health assessment by a non-physician.

So H0002 answers whether the patient should enter a program, and H0001 is the substance use assessment itself. H0031's descriptor covers a mental health assessment, not a substance use one.

For SBIRT, CMS says a state that covers it under Medicaid may choose which codes to bill. Its examples include G2011, G0396, G0397, G0442, G0443, H0049 and H0050 (CMS MLN904084, p. 12).

The record has to back the code. For Medicare SBIRT, CMS says the record must show start and stop times or total face-to-face time, plus the assessment, clinical impression and diagnosis for each encounter (CMS SBIRT documentation rules, p. 4). For Medicaid SBIRT, CMS points you to your state's documentation policy (MLN904084 Medicaid documentation section).

Next step: check that your intake template records time and findings, and that each payer gets the assessment code its own list names.

H0004 and 90837 aren't interchangeable. H0004 is counseling billed per 15 minutes, and 90837 is a 60-minute psychotherapy code.

The HCPCS file describes H0004 as behavioral health counseling and therapy, per 15 minutes, with coverage code I (HCPCS October 2026 file, H0004 row). 90837 carries the CMS short descriptor Psytx w pt 60 minutes and status A. Its CY2026 national non-facility amount is $167.00 before locality adjustment, which is 5.00 total RVUs times $33.4009 (CMS RVU26D, 90837 row).

If the payer counts full 15-minute units, a 60-minute counseling visit goes out as 4 units of H0004 to a payer that lists H codes and as 90837 to one that lists CPT codes. Revenue then depends on each payer's unit rate, not on which code looks bigger.

For the session codes themselves, see how the 90832, 90834 and 90837 session codes work.

Next step: build each payer's code list into scheduling so the visit type sets the code before the session starts.

Medicare lets many clinician types provide SUD services, but it pays some of them a smaller share of the fee schedule.

CMS lists the Medicare Part B providers who can provide substance use services (CMS MLN9560465, p. 3):

• Physicians and clinical psychologists
• Clinical social workers and clinical nurse specialists
• Nurse practitioners, physician assistants and certified nurse-midwives
• Independently practicing psychologists
• Marriage and family therapists
• Mental health counselors, including certified alcohol and drug counselors

Addiction counselors or alcohol and drug counselors who meet the mental health counselor requirements can enroll in Medicare as MHCs (CMS MLN1986542, p. 24).

Those percentages are from the CMS payment list in MLN9560465. For Medicaid, check your state's rules on who can render H0001 or H0004. We don't cover state rules here.

The cheapest clinician to staff an intake may not be one every payer will pay. Credential each rendering clinician with each payer before you schedule intakes for them.

Next step: list who does intakes today and check each one's enrollment with every payer they see.

Bill one assessment code for one evaluation unless the payer's policy allows more. Two assessment codes for the same visit, such as H0001 plus 90791, can report the same work twice.

For Medicare, NCCI procedure-to-procedure edits prevent inappropriate payment of services that should not be reported together (CMS Medicare NCCI PTP edits). CMS developed NCCI to promote national correct coding of Medicare Part B claims (CMS NCCI overview). For Medicaid and commercial plans, check the payer's own edits and policy.

If a claim is denied, the record has to support it. CMS says the patient's medical record must support all Medicare claims and warns that incomplete records place you at risk for partial or full Medicare payment denial, and its SBIRT list asks for time, the encounter reason, the assessment and diagnosis, the plan of care and signatures (CMS MLN904084 record list).

Run this check before each intake claim goes out:

• The code type, H code or CPT code, matches the payer's list.
• The rendering clinician is credentialed with that payer.
• Authorization is on file if the plan requires one for assessments.
• Only one assessment code is on the claim for the evaluation.
• The note is signed and shows time and findings.

This is general information, not legal or coding advice.

An audit of denied SUD intake claims shows where your codes and payers don't match.

Next step: pull last quarter's denied assessment claims and sort them by payer and code.

In the CMS files, the CPT evaluation and psychotherapy codes and the SBIRT G codes below are active Medicare codes, while the H codes and T1007 below are not valid for Medicare.

H, T and G code descriptors come from the HCPCS long descriptor file. CPT rows use the CMS short descriptors and status codes in the RVU26D payment file, where status N means the service isn't covered by Medicare.

For program-level codes, see the H0015 and S9480 intensive outpatient codes and the residential per diem codes.

Next step: compare this table with the code map in your billing system and flag any H code set to bill Medicare.