F11.21
BillableOpioid dependence, in remission
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F11.21 an HCC code?
Yes. F11.21 maps to Drug Use Disorder/Substance Use Disorder, Moderate/Severe under the CMS-HCC V28 risk adjustment model (and Drug/Alcohol Dependence 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 F11.21
For F11.21 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 F11.21 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F11.21 is the ICD-10-CM diagnosis code for opioid dependence, in remission. A person who was previously dependent on opioids but is now in remission, meaning they have stopped using opioids and are maintaining abstinence. F11.21 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, F11.21 maps to Drug Use Disorder/Substance Use Disorder, Moderate/Severe (HCC 137) with a community, non-dual, aged base RAF weight of 0.358. Under the older CMS-HCC V24 model, F11.21 maps to Drug/Alcohol Dependence (HCC 55) with a community, non-dual, aged base RAF weight of 0.334. 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.
Document the length of remission (early remission is typically less than 12 months; sustained remission is 12 months or longer). Because F11.21 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 F11.21 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the length of remission (early remission is typically less than 12 months; sustained remission is 12 months or longer)
- •Specify whether remission is on medication-assisted treatment (such as methadone or buprenorphine) or off medication
Clinical Significance
Opioid dependence, in remission indicates a patient with a history of opioid dependence who is currently in recovery. This is particularly important given the opioid epidemic, as it identifies patients who need ongoing monitoring, relapse prevention, and continued medication-assisted treatment support. The diagnosis should be maintained as long as the provider documents ongoing remission.
Documentation Requirements
- ✓Provider documentation of prior opioid dependence
- ✓Statement that the patient is currently in remission
- ✓Duration of remission (early: less than 12 months; sustained: 12+ months)
- ✓Current medication-assisted treatment status (methadone, buprenorphine, naltrexone) if applicable
- ✓Recovery support services and monitoring plan
- ✓Relapse risk assessment