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F28 ICD-10-CM Code: Other psychotic disorder not due to a substance or known physiological condition

F28 maps to CMS-HCC V28 152. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · HCC Buddy coding tools

ICD-10-CM Code View

HCC Buddy Code Card

Digital ICD-10 code-book layout with official code detail, always-visible risk models, Code Trumping, and Buddy coding guidance.

Code lookupF28

FY 2026 Apr update / Mental, Behavioral and Neurodevelopmental disorders (F01-F99) / Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F20-F29)

F28

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Other psychotic disorder not due to a substance or known physiological condition

A psychotic disorder where a person experiences hallucinations, delusions, or disorganized thinking that is not caused by substance use, medication, or a medical condition.

Buddy the Bee presenting code insight

Buddy Insight

Other psychotic disorder not due to a substance or known physiological condition is a diagnosis of exclusion for psychotic presentations that do not fit standard categories (schizophrenia, delusional disorder, brief psychotic disorder, schizoaffective disorder).

OverviewRisk ModelsCode BookDocumentationAuditNotesEdition comparison

CMS-HCC V28

HCC 152

Coefficient HCC 152: 0.484 (Community Non-Dual Aged (CNA))

CMS-HCC V24

Historical

Historical

Not used for CY2026 payment

ACA/HHS

Context needed

HCC 087_2

Coefficient needs member context

ESRD/PACE

Context needed

HCC 58

Coefficient needs member context

RXHCC

HCC 130

Code-level coefficient reference

Code Book Path

Official
F2Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F20-F29)F28Other psychotic disorder not due to a substance or known physiological condition

Inclusion Terms

Official
  • Chronic hallucinatory psychosis
  • Other specified schizophrenia spectrum and other psychotic disorder

Excludes 2

Official
  • symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99)Inherited from F01-F99

Related Codes

Official

No related codes are included in this display for F28. Check the Code Book for the complete code path.

Includes

Official
  • disorders of psychological developmentInherited from F01-F99

Excludes 1

Official

No Excludes 1 notes are included in this display for F28. Check the code and parent instructions in the Code Book.

Code First

Official

No Code First sequencing instructions are included in this display for F28. Check the code and parent instructions in the Code Book.

Use Additional

Official

No Use Additional Code instructions are included in this display for F28. Check the code and parent instructions in the Code Book.

Code Also

Official

No Code Also instructions are included in this display for F28. Check the code and parent instructions in the Code Book.

Buddy Documentation Tip

HCC Buddy guidance
Documentation of psychotic symptoms (hallucinations, delusions, disorganized thinking)
Assessment by a qualified mental health professional
Documentation ruling out substance-induced psychosis (drug screening, history)
Documentation ruling out psychosis due to medical conditions (metabolic, neurological, infectious workup)

MEAT Support

HCC Buddy guidance
Documentation of psychotic symptoms (hallucinations, delusions, disorganized thinking)
Assessment by a qualified mental health professional
Documentation ruling out substance-induced psychosis (drug screening, history)
Documentation ruling out psychosis due to medical conditions (metabolic, neurological, infectious workup)

Audit Caution

HCC Buddy guidance
Using F28 without documenting the exclusionary workup (substance use ruled out, medical causes ruled out)
Confusing 'other' psychotic disorder with 'unspecified' psychosis (F29) — different clinical implications
Not attempting to classify the psychosis more specifically before defaulting to this residual code
Coding F28 when symptoms actually fit a standard psychotic disorder category with further documentation review

Common Mistakes

HCC Buddy guidance
F29 — Unspecified psychosis is for when the type cannot be determined; F28 indicates a specific type was identified but does not fit standard categories
F20.89 — Other schizophrenia requires meeting full schizophrenia criteria; F28 does not
F22 — Delusional disorder involves only delusions; F28 may involve other psychotic features
F06.0/F06.2 — Psychotic disorders due to medical conditions should be used when an underlying medical cause is identified

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is F28 an HCC code?

Yes. F28 (Other psychotic disorder not due to a substance or known physiological condition) maps to HCC 152, Psychosis, Except Schizophrenia under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.484. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.

Coder answer: F28 is billable and maps to V28 HCC 152, Psychosis, Except Schizophrenia. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code
F28
Description
Other psychotic disorder not due to a substance or known physiological condition
HCC (V28)
HCC 152 — Psychosis, Except Schizophrenia
RAF reference coefficient
0.484
Billable
Yes
Payment year
2026

HCC Category Mapping

V28HCC 152, Psychosis, Except Schizophrenia
0.484
RxHCCHCC 130, Schizophrenia and Other Psychosis
Not separately weighted

These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. Weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.

Work F28 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →

MEAT review for F28

For F28, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.

  • 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

Coder workflow notes

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What This Code Means

F28 is the ICD-10-CM diagnosis code for other psychotic disorder not due to a substance or known physiological condition. A psychotic disorder where a person experiences hallucinations, delusions, or disorganized thinking that is not caused by substance use, medication, or a medical condition. F28 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, F28 maps to Psychosis, Except Schizophrenia (HCC 152) with a source-labeled community, non-dual, aged reference coefficient of 0.484. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.

Ensure documentation rules out substance use, medication effects, and medical causes before coding. For F28, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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, source-labeled coefficient references, and MEAT documentation criteria for F28 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

  • •Ensure documentation rules out substance use, medication effects, and medical causes before coding
  • •This is a diagnosis of exclusion; document the workup performed to eliminate other causes

Clinical Significance

Other psychotic disorder not due to a substance or known physiological condition is a diagnosis of exclusion for psychotic presentations that do not fit standard categories (schizophrenia, delusional disorder, brief psychotic disorder, schizoaffective disorder). This may include chronic hallucinatory psychosis or other atypical psychotic presentations. It requires thorough clinical evaluation to exclude substance-induced and medical causes of psychosis. Accurate coding ensures these complex patients receive appropriate risk adjustment.

Documentation Requirements

  • ✓Documentation of psychotic symptoms (hallucinations, delusions, disorganized thinking)
  • ✓Assessment by a qualified mental health professional
  • ✓Documentation ruling out substance-induced psychosis (drug screening, history)
  • ✓Documentation ruling out psychosis due to medical conditions (metabolic, neurological, infectious workup)
  • ✓Explanation of why the presentation does not fit schizophrenia, delusional disorder, brief psychotic disorder, or schizoaffective disorder
  • ✓Current treatment plan and functional assessment

Commonly Confused Codes

  • •F29: Unspecified psychosis is for when the type cannot be determined; F28 indicates a specific type was identified but does not fit standard categories
  • •F20.89: Other schizophrenia requires meeting full schizophrenia criteria; F28 does not
  • •F22: Delusional disorder involves only delusions; F28 may involve other psychotic features
  • •F06.0/F06.2: Psychotic disorders due to medical conditions should be used when an underlying medical cause is identified
  • •F1X.950/F1X.951: Substance-induced psychotic disorders should be used when substance etiology is established

Code Hierarchy

└F28Other psychotic disorder not due to a substance or known physiological condition
└F28Other psychotic disorder not due to a substance or known physiological condition

For F28, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.

F28 maps to CMS-HCC V28 category 152, Psychosis, Except Schizophrenia. See the ICD-10 to HCC mapping hub for how the V28 crosswalk works. The mapping identifies a payment HCC category for F28. Review its source-labeled HCC coefficient above, check the RAF Calculator with complete member context for CMS-HCC V28 PY2026, and confirm the documentation the chart needs before the code is submitted. HCC Buddy shows no RAF score unless every required source and calculation check passes.

Work F28 in HCC Buddy

Open F28 in the Code Book for the full Index-to-Tabular path, MEAT checklist, and V28 HCC mapping, or in the Encoder to code from a keyword search. Pro includes 7 days to try everything, no card required.

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