F16.250
BillableHallucinogen dependence with hallucinogen-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 F16.250 an HCC code?
Yes. F16.250 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 F16.250
For F16.250 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 F16.250 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F16.250 is the ICD-10-CM diagnosis code for hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions. A person is dependent on hallucinogenic drugs (like LSD or psilocybin) and is experiencing a mental health condition where they have false beliefs (delusions) caused by the hallucinogen use. This represents both the addiction and the psychiatric symptoms occurring together. F16.250 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, F16.250 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F16.250 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.
This code requires documentation of both the hallucinogen dependence AND the hallucinogen-induced psychotic disorder with delusions to be present; do not use this code if only one condition exists. Because F16.250 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 F16.250 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This code requires documentation of both the hallucinogen dependence AND the hallucinogen-induced psychotic disorder with delusions to be present; do not use this code if only one condition exists
- •The fifth character '0' indicates the current episode is not in remission; if the patient is in early remission or sustained remission, use F16.251 or F16.252 respectively
Clinical Significance
This code captures the highest-severity hallucinogen dependence presentation — dependence combined with substance-induced psychotic disorder featuring delusions. Delusions from hallucinogen use can persist beyond intoxication and may require antipsychotic treatment, psychiatric hospitalization, and long-term monitoring for chronic psychotic features.
Documentation Requirements
- ✓Documentation of hallucinogen dependence
- ✓Specific documentation of delusions (false fixed beliefs) as the psychotic feature
- ✓Provider statement linking the psychotic disorder to hallucinogen use
- ✓Mental status examination documenting delusional content and type
- ✓Differentiation from primary psychotic disorders (schizophrenia, delusional disorder)
- ✓Treatment plan addressing both dependence and psychotic symptoms
Commonly Confused Codes
- •F16.251 — Hallucinogen dependence with psychotic disorder with hallucinations; use when hallucinations predominate over delusions
- •F16.259 — Hallucinogen dependence with psychotic disorder, unspecified; less specific regarding psychotic features
- •F16.150 — Hallucinogen abuse with psychotic disorder with delusions; use when abuse rather than dependence
- •F20.0 — Paranoid schizophrenia; use for primary psychotic disorder not induced by substance use