F16.11
BillableHallucinogen abuse, in remission
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F16.11 an HCC code?
Yes. F16.11 maps to Drug Use Disorder/Substance Use Disorder, Mild under the CMS-HCC V28 risk adjustment model (and Drug/Alcohol Abuse, Without 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 F16.11
For F16.11 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 F16.11 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F16.11 is the ICD-10-CM diagnosis code for hallucinogen abuse, in remission. A condition where someone previously abused hallucinogenic drugs but is now in recovery or remission from that abuse. F16.11 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, F16.11 maps to Drug Use Disorder/Substance Use Disorder, Mild (HCC 138) with a community, non-dual, aged base RAF weight of 0.476. Under the older CMS-HCC V24 model, F16.11 maps to Drug/Alcohol Abuse, Without Dependence (HCC 56) with a community, non-dual, aged base RAF weight of 0.000. 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 when the patient has achieved sustained abstinence or controlled use. Because F16.11 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 F16.11 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use this code when the patient has achieved sustained abstinence or controlled use
- •Document the length of remission and any ongoing treatment or support services
Clinical Significance
Hallucinogen abuse in remission indicates a patient who previously met criteria for hallucinogen abuse but has achieved recovery status. Despite remission, these patients remain at risk for relapse and may experience long-term psychiatric effects including hallucinogen persisting perception disorder (flashbacks). Continued monitoring and documentation of remission status supports ongoing risk adjustment and clinical surveillance.
Documentation Requirements
- ✓History of hallucinogen abuse documented
- ✓Provider explicitly documents remission status (early remission, sustained remission)
- ✓Duration of remission documented when available
- ✓Assessment for persistent perceptual symptoms or psychiatric sequelae
- ✓Ongoing monitoring plan or discharge from substance use treatment