F19.250
BillableOther psychoactive substance dependence with psychoactive substance-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 F19.250 an HCC code?
Yes. F19.250 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 F19.250
For F19.250 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 F19.250 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F19.250 is the ICD-10-CM diagnosis code for other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions. A person is dependent on drugs or substances (other than alcohol, opioids, cannabis, stimulants, hallucinogens, or inhalants) and is experiencing psychotic symptoms including false beliefs (delusions) caused by the substance use. This represents a serious mental health condition where substance addiction has triggered hallucinations or delusional thinking. F19.250 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, F19.250 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F19.250 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.
Verify the specific substance involved is documented and does not fit into other F19 subcategories (alcohol, opioids, cannabis, stimulants, hallucinogens, inhalants) before assigning F19. Because F19.250 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 F19.250 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify the specific substance involved is documented and does not fit into other F19 subcategories (alcohol, opioids, cannabis, stimulants, hallucinogens, inhalants) before assigning F19
- •Ensure clinical documentation clearly links the psychotic symptoms with delusions to the substance use rather than a primary psychotic disorder, and confirm active dependence is present
Clinical Significance
This code captures substance-induced psychotic disorder, which represents a serious psychiatric complication of other psychoactive substance dependence. Substance-induced psychosis significantly increases healthcare utilization, emergency department visits, and hospitalization risk, making accurate capture critical for risk adjustment. These patients require intensive psychiatric management and close monitoring for progression to chronic psychotic disorders.
Documentation Requirements
- ✓Provider documentation specifying the psychoactive substance(s) involved (e.g., designer drugs, bath salts, kratom, polysubstance use)
- ✓Clinical documentation supporting dependence criteria: tolerance, withdrawal symptoms, compulsive use despite harm, or inability to control use
- ✓Documentation of fixed false beliefs (delusions) that developed during or shortly after substance use and are directly attributable to the substance
- ✓Assessment and plan addressing the substance use disorder with treatment approach documented
Commonly Confused Codes
- •F19.10-F19.19 (Other psychoactive substance abuse) — abuse indicates a less severe use pattern without meeting dependence criteria
- •F19.90-F19.99 (Other psychoactive substance use, unspecified) — unspecified use is used when the severity of the use disorder is not documented
- •F19.251 (Psychotic disorder with hallucinations) — hallucinations are false sensory perceptions; delusions are fixed false beliefs
- •F20-F29 (Schizophrenia spectrum disorders) — primary psychotic disorders are not substance-induced; confirm temporal relationship with substance use
- •F10-F16 (Specific substance codes: alcohol, opioids, cannabis, sedatives, cocaine, stimulants) — use substance-specific codes when the substance is identified; F19 is for 'other' or multiple unspecified substances