F11.20 maps to CMS-HCC V28 137. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · HCC Buddy coding tools

ICD-10-CM Code View

HCC Buddy Code Card

Digital ICD-10 code-book layout with official code detail, always-visible risk models, Code Trumping, and Buddy coding guidance.

Code lookupF11.20

Effective periodFY2026 Apr Update (Apr 1-Sep 30)

FY 2026 Apr update / Mental, Behavioral and Neurodevelopmental disorders (F01-F99) / Mental and behavioral disorders due to psychoactive substance use (F10-F19)

F11.20

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Opioid dependence, uncomplicated

A person who is dependent on opioids (unable to stop using despite wanting to) and has no current complications from the dependence.

Buddy Insight

Overview Risk Models Code Book Documentation Audit Notes Edition comparison

CMS-HCC V28

Mapped

HCC 137

Drug Use Disorder, Moderate/S...

Coefficient HCC 137: 0.424 (Community Non-Dual Aged (CNA))

CMS-HCC V24

Historical

Not used for standard CY2026 Medicare Advantage payment. Select a historical period to review V24.

Not used for CY2026 payment

ACA/HHS

Mapped

HCC 082

HHS-HCC 082 adult, RAF varies...

Code-level coefficient reference

ESRD/PACE

Mapped

HCC 55

Substance Use Disorder/Modera...

Code-level coefficient reference

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

Inclusion Terms

Official

Opioid use disorder, moderate
Opioid use disorder, severe

Excludes 2

Official

symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99)Inherited from F01-F99, F11.2
opioid poisoning (T40.0-T40.2-)Inherited from F01-F99, F11.2

Related Codes

Official

F11.21Opioid dependence, in remission F11.22Opioid dependence with intoxication F11.23Opioid dependence with withdrawal F11.24Opioid dependence with opioid-induced mood disorder F11.25Opioid dependence with opioid-induced psychotic disorder

Includes

Official

disorders of psychological developmentInherited from F01-F99

Excludes 1

Official

opioid abuse (F11.1-)Inherited from F11.2
opioid use, unspecified (F11.9-)Inherited from F11.2

Code First

Official

No Code First sequencing instructions are included in this display for F11.20. Check the code and parent instructions in the Code Book.

Use Additional

Official

No Use Additional Code instructions are included in this display for F11.20. Check the code and parent instructions in the Code Book.

Code Also

Official

No Code Also instructions are included in this display for F11.20. Check the code and parent instructions in the Code Book.

Buddy Documentation Tip

HCC Buddy guidance

Provider documentation explicitly stating opioid dependence (not just abuse or use)

Evidence of dependence criteria: tolerance, withdrawal potential, compulsive use, continued use despite harm

Type of opioid if documented (heroin, prescription opioids, fentanyl)

Current treatment status (medication-assisted treatment: methadone, buprenorphine, naltrexone)

MEAT Support

HCC Buddy guidance

Provider documentation explicitly stating opioid dependence (not just abuse or use)

Evidence of dependence criteria: tolerance, withdrawal potential, compulsive use, continued use despite harm

Type of opioid if documented (heroin, prescription opioids, fentanyl)

Current treatment status (medication-assisted treatment: methadone, buprenorphine, naltrexone)

Audit Caution

HCC Buddy guidance

Coding abuse when documentation supports dependence — these are clinically distinct with different HCC implications

Using 'in remission' when the patient is still actively dependent

Not capturing dependence when the patient is on medication-assisted treatment — patients on methadone or buprenorphine are still coded as dependent

Failing to distinguish between uncomplicated dependence and dependence with active complications

Common Mistakes

HCC Buddy guidance

F11.10 — Opioid abuse, uncomplicated: use when abuse (not dependence) criteria are met

F11.21 — Opioid dependence, in remission: use when the patient is in documented remission

F11.90 — Opioid use, unspecified, uncomplicated: use when the pattern cannot be classified as abuse or dependence

F11.23 — Opioid dependence with withdrawal: use when active withdrawal symptoms are present

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is F11.20 an HCC code?

Yes. F11.20 (Opioid dependence, uncomplicated) maps to HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.424. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.

Coder answer: F11.20 is billable and maps to V28 HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code: F11.20
Description: Opioid dependence, uncomplicated
HCC (V28): HCC 137 — Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications
RAF reference coefficient: 0.424
Billable: Yes
Payment year: 2026

HCC Category Mapping

V28HCC 137, Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications

0.424

ESRDHCC 55, Substance Use Disorder/Moderate/Severe/Substance Use with Complications

Not separately weighted

These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. Weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.

Work F11.20 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT review for F11.20

For F11.20, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.

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

Coder workflow notes

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What This Code Means

F11.20 is the ICD-10-CM diagnosis code for opioid dependence, uncomplicated. A person who is dependent on opioids (unable to stop using despite wanting to) and has no current complications from the dependence. F11.20 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, F11.20 maps to Drug Use Disorder, Moderate/Severe, or Drug Use with Non-Psychotic Complications (HCC 137) with a source-labeled community, non-dual, aged reference coefficient of 0.424. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.

Opioid dependence, uncomplicated. Provider documents opioid dependence without acute intoxication or withdrawal. Typically includes maintenance therapy (methadone, buprenorphine) or chronic dependence with ongoing management. For F11.20, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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, source-labeled coefficient references, and MEAT documentation criteria for F11.20 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•Opioid dependence, uncomplicated. Provider documents opioid dependence without acute intoxication or withdrawal. Typically includes maintenance therapy (methadone, buprenorphine) or chronic dependence with ongoing management.
•Do not report F11.20 alongside F11.21 (in remission), match the code to current status. Also, F11.20 is distinct from F11.10 (abuse), dependence carries a higher HCC weight in V28.

Clinical Significance

Opioid dependence, uncomplicated is a critical diagnosis indicating physiological and psychological addiction to opioids with tolerance and withdrawal potential, but without current active complications. This diagnosis captures a chronic condition requiring ongoing management, often including medication-assisted treatment, and reflects significant expected healthcare utilization.

Documentation Requirements

✓Provider documentation explicitly stating opioid dependence (not just abuse or use)
✓Evidence of dependence criteria: tolerance, withdrawal potential, compulsive use, continued use despite harm
✓Type of opioid if documented (heroin, prescription opioids, fentanyl)
✓Current treatment status (medication-assisted treatment: methadone, buprenorphine, naltrexone)
✓Confirmation that no current complications (intoxication, withdrawal, induced disorders) are present
✓Treatment and monitoring plan

Commonly Confused Codes

•F11.10: Opioid abuse, uncomplicated: use when abuse (not dependence) criteria are met
•F11.21: Opioid dependence, in remission: use when the patient is in documented remission
•F11.90: Opioid use, unspecified, uncomplicated: use when the pattern cannot be classified as abuse or dependence
•F11.23: Opioid dependence with withdrawal: use when active withdrawal symptoms are present