F19.251
BillableOther psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F19.251 an HCC code?
Yes. F19.251 maps to Drug Use with Psychotic Complications under the CMS-HCC V28 risk adjustment model (and Substance Use with Psychotic Complications 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 F19.251
For F19.251to 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 F19.251 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F19.251 is the ICD-10-CM diagnosis code for other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations. Addiction to various drugs or substances that causes psychosis with hallucinations, where the person sees, hears, or experiences things that aren't real. F19.251 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, F19.251 maps to Drug Use with Psychotic Complications (HCC 135) with a community, non-dual, aged base RAF weight of 0.424. Under the older CMS-HCC V24 model, F19.251 maps to Substance Use with Psychotic Complications (HCC 54) with a community, non-dual, aged base RAF weight of 0.329. 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.
Document the type of hallucinations present (visual, auditory, tactile, etc.) in the clinical record. Because F19.251 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 F19.251 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the type of hallucinations present (visual, auditory, tactile, etc.) in the clinical record
- •Ensure documentation clearly indicates the psychotic symptoms are substance-induced rather than primary psychosis
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 hallucinations (visual, auditory, tactile) that developed during or shortly after substance use, with the provider confirming they are substance-induced
- ✓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
- •F19.250 (Psychotic disorder with delusions) — delusions are fixed false beliefs; hallucinations are false sensory perceptions
- •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