F03.C11
BillableUnspecified dementia, severe, with agitation
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F03.C11 an HCC code?
Yes. F03.C11 maps to Dementia, Severe under the CMS-HCC V28 risk adjustment model.
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for F03.C11
For F03.C11 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed F03.C11 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F03.C11 is the ICD-10-CM diagnosis code for unspecified dementia, severe, with agitation. Severe dementia accompanied by agitation, where the person exhibits restlessness, irritability, or aggressive behavior due to their advanced cognitive decline. F03.C11 sits in the ICD-10-CM chapter for mental, behavioral and neurodevelopmental disorders (f01-f99), within the section covering mental disorders due to known physiological conditions (f01-f09).
Under the CMS-HCC V28 risk adjustment model, F03.C11 maps to Dementia, Severe (HCC 125) with a community, non-dual, aged base RAF weight of 0.885. F03.C11 was not retained as a payment HCC under the older V24 model, so V28 introduced or recategorized it during the 2024–2026 phase-in. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Ensure agitation is specifically documented in the clinical notes as a behavioral disturbance. Because F03.C11 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for F03.C11 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Ensure agitation is specifically documented in the clinical notes as a behavioral disturbance
- •Confirm severity is documented as severe, not moderate or mild
Clinical Significance
This code captures severe unspecified dementia with agitation, representing significant cognitive impairment that affects the patient's functional status and care needs. Severe dementia carries substantial risk adjustment weight because these patients require intensive care coordination, caregiver support, and monitoring for complications. Accurate severity staging and behavioral documentation directly impact both clinical management and appropriate resource allocation.
Documentation Requirements
- ✓Provider documentation explicitly stating dementia severity as 'severe'
- ✓Cognitive assessment results (e.g., MMSE, MoCA, or SLUMS score) supporting the stated severity level
- ✓Functional status assessment documenting impact on activities of daily living
- ✓Statement that underlying etiology is unknown or unspecified (if a known cause exists, use a more specific dementia code)
- ✓Documentation of agitation behaviors (e.g., verbal or physical aggression, restlessness) as a manifestation of the dementia
Commonly Confused Codes
- •F03.B0 — Unspecified dementia, moderate, without behavioral disturbance; lower severity level
- •F01.C0 through F01.C4 — Vascular dementia, severe; use when documentation attributes dementia to cerebrovascular disease
- •F02.C0 through F02.C4 — Dementia in other diseases classified elsewhere, severe; use when a known underlying condition causes the dementia (code underlying condition first)
- •G30.9 with F02 codes — Alzheimer disease with dementia; use F02 codes when Alzheimer is the documented cause