F12.259
BillableCannabis dependence with psychotic disorder, unspecified
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F12.259 an HCC code?
Yes. F12.259 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 F12.259
For F12.259 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 F12.259 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F12.259 is the ICD-10-CM diagnosis code for cannabis dependence with psychotic disorder, unspecified. This code describes a patient who is dependent on cannabis (marijuana) and experiences psychotic symptoms such as hallucinations or delusions, but the specific type of psychotic disorder has not been identified. The psychotic symptoms are directly related to the cannabis use. F12.259 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, F12.259 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F12.259 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.
Verify documentation clearly states both cannabis dependence AND a psychotic disorder; if only one condition is present, use a different code. Because F12.259 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 F12.259 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify documentation clearly states both cannabis dependence AND a psychotic disorder; if only one condition is present, use a different code
- •If the specific psychotic disorder is documented (such as schizophreniform disorder or brief psychotic disorder), use the more specific F12.25x code rather than the unspecified variant
Clinical Significance
Cannabis dependence with unspecified psychotic disorder captures a dependent patient with cannabis-induced psychosis when the specific type of psychotic features is not documented. While this still maps to the highest substance use HCC category (HCC 54 in V24), more specific documentation of delusions versus hallucinations would improve clinical precision. This code indicates serious psychiatric comorbidity requiring both addiction and psychiatric treatment.
Documentation Requirements
- ✓Documentation of cannabis dependence
- ✓Statement that psychotic disorder is present and cannabis-induced
- ✓Any available clinical details about the psychotic presentation
- ✓Evidence that provider was queried about specific psychotic features
- ✓Temporal relationship between cannabis use and psychosis