F11.99
BillableOpioid use, unspecified with unspecified opioid-induced disorder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F11.99 an HCC code?
Yes. F11.99 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 F11.99
For F11.99 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 F11.99 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F11.99 is the ICD-10-CM diagnosis code for opioid use, unspecified with unspecified opioid-induced disorder. A person is using opioids in an unspecified manner and has developed an unspecified opioid-related disorder, but the specific pattern of use or type of disorder is not documented. F11.99 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, F11.99 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, F11.99 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.
Use this code only when the documentation does not specify the type of opioid use (abuse vs. dependence) or the specific opioid-induced disorder. Because F11.99 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 F11.99 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 the documentation does not specify the type of opioid use (abuse vs. dependence) or the specific opioid-induced disorder
- •Query the provider for more specific information about the pattern of use and any associated conditions to assign a more precise code
Clinical Significance
This is the least specific code for opioid use with an opioid-induced disorder, used when neither the pattern of use nor the type of induced disorder is documented. While it still captures the clinical complexity of opioid-related complications for risk adjustment purposes, more specific coding should always be pursued. This code signals a documentation gap that coders should address through provider queries.
Documentation Requirements
- ✓Documentation of opioid use (any pattern)
- ✓Statement that an opioid-induced disorder is present
- ✓Evidence that more specific information about the disorder type was sought but unavailable
- ✓Clinical notes supporting the presence of complications beyond simple opioid use