F20.5
BillableResidual schizophrenia
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is F20.5 an HCC code?
Yes. F20.5 maps to Schizophrenia under the CMS-HCC V28 risk adjustment model (and Schizophrenia 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 F20.5
For F20.5 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 F20.5 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
F20.5 is the ICD-10-CM diagnosis code for residual schizophrenia. A chronic form of schizophrenia where the acute psychotic symptoms have largely resolved, but the person continues to experience negative symptoms like social withdrawal, lack of motivation, or reduced emotional expression. F20.5 sits in the ICD-10-CM chapter for mental, behavioral and neurodevelopmental disorders (f01-f99), within the section covering schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (f20-f29).
Under the CMS-HCC V28 risk adjustment model, F20.5 maps to Schizophrenia (HCC 151) with a community, non-dual, aged base RAF weight of 0.244. Under the older V24 model, F20.5 mapped to the same category but with a base RAF weight of 0.508 — 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.
Confirm that acute psychotic symptoms are no longer prominent and negative symptoms predominate. Because F20.5 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 F20.5 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Confirm that acute psychotic symptoms are no longer prominent and negative symptoms predominate
- •Document the history of prior schizophrenic episodes to establish residual phase
Clinical Significance
Residual schizophrenia describes the chronic phase where acute psychotic symptoms (delusions, hallucinations) have largely resolved but negative symptoms persist (social withdrawal, flat affect, alogia, avolition). This phase represents the long-term functional impact of schizophrenia and requires ongoing treatment and psychosocial support. Despite the resolution of acute symptoms, these patients remain significantly impaired and the HCC appropriately captures their ongoing care needs.
Documentation Requirements
- ✓Established history of schizophrenia with prior psychotic episodes documented
- ✓Assessment showing acute psychotic symptoms are no longer prominent
- ✓Documentation of persistent negative symptoms (flat affect, social withdrawal, alogia, avolition, anhedonia)
- ✓Current functional assessment showing ongoing impairment despite resolution of acute psychosis
- ✓Current medication regimen (often continued antipsychotics for relapse prevention)
- ✓Psychosocial support plan and rehabilitation services
Commonly Confused Codes
- •F20.0-F20.3 — Active schizophrenia subtypes should be used when acute psychotic symptoms are still prominent
- •F20.9 — Schizophrenia, unspecified does not convey the specific residual phase
- •F21 — Schizotypal disorder is a personality disorder, not a phase of schizophrenia
- •F20.81 — Schizophreniform disorder has a time-limited course, unlike residual schizophrenia
- •F60.1 — Schizoid personality disorder shares some features but is a personality disorder, not schizophrenia