F11.159
BillableOpioid abuse with opioid-induced psychotic disorder, unspecified
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F11.159 an HCC code?
Yes. F11.159 maps to Drug Use with Psychotic Complications under the CMS-HCC V28 risk adjustment model (and Substance Use with Psychotic Complications under V24).
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 F11.159
For F11.159to 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 F11.159 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F11.159 is the ICD-10-CM diagnosis code for opioid abuse with opioid-induced psychotic disorder, unspecified. A person who misuses opioids and experiences psychotic symptoms caused by the opioid use, but the specific type of psychotic symptom is not documented or specified. F11.159 sits in the ICD-10-CM chapter for mental, behavioral and neurodevelopmental disorders (f01-f99), within the section covering mental and behavioral disorders due to psychoactive substance use (f10-f19).
Under the CMS-HCC V28 risk adjustment model, F11.159 maps to Drug Use with Psychotic Complications (HCC 135) with a community, non-dual, aged base RAF weight of 0.424. Under the older CMS-HCC V24 model, F11.159 maps to Substance Use with Psychotic Complications (HCC 54) with a community, non-dual, aged base RAF weight of 0.329. 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.
Use this code only when the type of psychotic disorder is not clearly documented. Because F11.159 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 F11.159 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use this code only when the type of psychotic disorder is not clearly documented
- •Query the provider if hallucinations, delusions, or other specific psychotic features are present to allow for more specific coding
Clinical Significance
Opioid abuse with opioid-induced psychotic disorder, unspecified captures cases where opioid-induced psychosis is documented but the specific type (delusions vs. hallucinations) is not differentiated. This code should prompt a query for more specific documentation to improve both clinical care and coding accuracy.
Documentation Requirements
- ✓Provider documentation of opioid abuse
- ✓Statement that psychotic symptoms are opioid-induced
- ✓Documentation that psychosis is present but type not specified
- ✓Mental status examination supporting psychotic features
- ✓Assessment ruling out primary psychotic disorders
Commonly Confused Codes
- •F11.150 — Opioid abuse with psychotic disorder with delusions: use when delusions are specified
- •F11.151 — Opioid abuse with psychotic disorder with hallucinations: use when hallucinations are specified
- •F11.259 — Opioid dependence with psychotic disorder, unspecified: use when dependence is documented
- •F29 — Unspecified psychosis not due to a substance: use when psychosis is NOT substance-induced