Patient presents today with concerns regarding substance use, meeting criteria for Substance Use Disorder (SUD).  The patient reports a history of [Specific Substance, e.g., alcohol, opioid, stimulant] use, escalating in frequency and quantity over the past [Timeframe, e.g., six months, two years].  Symptoms include [Specific DSM-5 Criteria, e.g., craving, withdrawal symptoms, tolerance, continued use despite negative consequences].  The patient acknowledges impairment in social, occupational, or recreational functioning due to substance use.  A detailed substance use history was obtained, including route of administration, frequency, quantity, and duration.  Family history is positive for [Specific Substance Use Disorder if applicable].  Physical examination revealed [Relevant physical findings, e.g., elevated blood pressure, track marks].  Mental status examination indicates [Patient's mental state, e.g., anxious, depressed, agitated].  Differential diagnoses considered include [Other potential diagnoses, e.g., mood disorder, anxiety disorder].  Assessment suggests a diagnosis of [Severity of SUD, e.g., mild, moderate, severe] Substance Use Disorder, [Specific Substance, e.g., alcohol, opioid, stimulant] type, based on DSM-5 criteria.  The patient was educated on the risks and consequences of continued substance use and treatment options were discussed, including individual therapy, group therapy, medication-assisted treatment (MAT), and referral to a higher level of care if necessary.  The patient expressed willingness to engage in treatment.  A treatment plan was initiated, focusing on abstinence, relapse prevention, and developing coping mechanisms.  Follow-up appointment scheduled in [Timeframe, e.g., one week, two weeks] to monitor progress and adjust treatment as needed.  ICD-10 code [Appropriate ICD-10 code, e.g., F10.20] is assigned.  Medical billing codes for evaluation and management (E/M) services will be determined based on time spent and complexity of medical decision making.