F11.950
BillableOpioid use, unspecified with opioid-induced psychotic disorder with delusions
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F11.950 an HCC code?
Yes. F11.950 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 F11.950
For F11.950 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 F11.950 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F11.950 is the ICD-10-CM diagnosis code for opioid use, unspecified with opioid-induced psychotic disorder with delusions. False beliefs or delusions that occur as a direct result of opioid use, such as believing someone is trying to harm them. F11.950 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, F11.950 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F11.950 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.
Document the specific delusions present and their temporal relationship to opioid use. Because F11.950 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 F11.950 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the specific delusions present and their temporal relationship to opioid use
- •Ensure documentation clarifies this is opioid-induced, not a primary psychotic disorder
Clinical Significance
Opioid use, unspecified with opioid-induced psychotic disorder with delusions indicates opioid use is causing fixed false beliefs in a patient whose use pattern is not classified. This severe psychiatric complication requires urgent evaluation, differentiation from primary psychotic disorders, and integrated treatment addressing both substance use and psychosis.
Documentation Requirements
- ✓Documentation of specific delusions (paranoid, grandiose, persecutory, somatic)
- ✓Provider statement that delusions are opioid-induced
- ✓Temporal relationship between opioid use and delusional onset
- ✓Mental status examination documenting delusional content and thought process
- ✓Assessment ruling out schizophrenia, schizoaffective disorder, and other primary psychotic disorders
- ✓Documentation of opioid use (though pattern not classified)
- ✓Safety assessment and treatment plan