F11.959
BillableOpioid use, unspecified 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 F11.959 an HCC code?
Yes. F11.959 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 F11.959
For F11.959 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 F11.959 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F11.959 is the ICD-10-CM diagnosis code for opioid use, unspecified with opioid-induced psychotic disorder, unspecified. Psychotic symptoms caused by opioid use when the specific type of psychotic symptom is not clearly documented or specified. F11.959 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, F11.959 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F11.959 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 only when documentation does not specify delusions or hallucinations. Because F11.959 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 F11.959 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
Clinical Significance
Opioid-induced psychotic disorder represents a severe psychiatric complication of opioid use that requires urgent intervention and indicates high clinical complexity. This diagnosis is significant for risk adjustment because it captures the intersection of substance use and psychosis, reflecting increased healthcare utilization and the need for both psychiatric and addiction treatment services. Accurate capture ensures appropriate resource allocation for these medically complex patients.
Documentation Requirements
- ✓Documentation of opioid use (specific opioid substance if known)
- ✓Description of psychotic symptoms (hallucinations, delusions, or unspecified)
- ✓Temporal relationship between opioid use and onset of psychotic symptoms
- ✓Statement that psychotic disorder is induced by opioid use, not a primary psychotic disorder
- ✓Current pattern of opioid use (use, abuse, or dependence) — if determinable
- ✓Mental status examination findings supporting psychosis