F11.259
BillableOpioid dependence 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 F11.259 an HCC code?
Yes. F11.259 maps to Drug/Alcohol Psychosis under the CMS-HCC V28 risk adjustment model (and Drug/Alcohol Psychosis 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 F11.259
For F11.259 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 F11.259 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F11.259 is the ICD-10-CM diagnosis code for opioid dependence with opioid-induced psychotic disorder, unspecified. A person is dependent on opioids and experiences psychotic symptoms caused by opioid use, but the specific type of psychotic symptoms is not documented. F11.259 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, F11.259 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F11.259 mapped to the same category but with a base RAF weight of 0.434 — V28 recalibrated weights across the entire model. 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 psychotic disorder is present but the specific manifestation (delusions vs. hallucinations) is not documented. Because F11.259 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 F11.259 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 psychotic disorder is present but the specific manifestation (delusions vs. hallucinations) is not documented
- •Encourage documentation of the specific psychotic features for more accurate coding
Clinical Significance
Opioid dependence with opioid-induced psychotic disorder, unspecified captures opioid-induced psychosis in a dependent patient where the specific type (delusions vs. hallucinations) is not documented. While still capturing HCC 54 in V24, this unspecified code should prompt provider query for better specificity.
Documentation Requirements
- ✓Provider documentation of opioid dependence
- ✓Statement that psychotic symptoms are opioid-induced
- ✓Documentation that psychosis is present but specific type is not documented
- ✓Mental status examination supporting psychotic features
- ✓Assessment ruling out primary psychotic disorders