F19.96
BillableOther psychoactive substance use, unspecified with psychoactive substance-induced persisting amnestic disorder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F19.96 an HCC code?
Yes. F19.96 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 F19.96
For F19.96 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 F19.96 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F19.96 is the ICD-10-CM diagnosis code for other psychoactive substance use, unspecified with psychoactive substance-induced persisting amnestic disorder. A long-lasting memory disorder where someone has difficulty forming or recalling new memories as a lasting effect of psychoactive substance use. F19.96 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, F19.96 maps to Drug/Alcohol Psychosis (HCC 135) with a community, non-dual, aged base RAF weight of 0.000. Under the older V24 model, F19.96 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 indicates a persisting condition that continues even after substance use stops. Because F19.96 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 F19.96 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This code indicates a persisting condition that continues even after substance use stops
- •Document the severity and functional impact of the memory impairment
Clinical Significance
Other psychoactive substance use, unspecified with substance-induced persisting amnestic disorder represents a permanent or long-lasting memory impairment caused by substance use that continues even after the substance is discontinued. This is a serious neurological consequence of substance abuse, analogous to Korsakoff syndrome seen with alcohol. The 'persisting' designation indicates this is not a transient effect but a lasting cognitive deficit requiring ongoing care.
Documentation Requirements
- ✓Documentation of current or historical psychoactive substance use
- ✓Neuropsychological assessment or cognitive testing demonstrating memory impairment
- ✓Provider determination that amnestic disorder is substance-induced and persisting beyond active use
- ✓Description of specific memory deficits (anterograde amnesia, retrograde amnesia, confabulation)
- ✓Functional impact assessment on activities of daily living
- ✓Neuroimaging findings if available (brain atrophy, white matter changes)