2027 ICD-10-CM Diagnosis Code F11.959Opioid use, unspecified with opioid-induced psychotic disorder, unspecified
F11.959 is a billable ICD-10-CM diagnosis code for opioid use, unspecified with opioid-induced psychotic disorder, unspecified. It is valid on HIPAA claims for fiscal year 2027 (October 1, 2026 through September 30, 2027) and groups to MS-DRG 894 through 897. Coders also document this condition as psychotic disorder caused by opioid. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Opioid-related disorders and Schizophrenia spectrum and other psychotic disorders.
For Medicare Advantage risk adjustment, F11.959 maps to CMS-HCC Category 135 (Drug Use with Psychotic Complications) under the V28 model, adding a risk factor of about 0.424 for a community, non-dual, aged beneficiary in payment year 2027.
Code Identity
Code Classification
Medicare Risk Adjustment (HCC)Billing
F11.959 maps to a payment category in the CMS-HCC model used to risk-adjust Medicare Advantage payments. Weights are the published community factors for payment year 2027.
Source: CMS Payment Year 2027 risk adjustment mappings and model software. Weights are relative factors, not dollar amounts; a beneficiary's total RAF also includes demographics and interactions. Browse all CMS-HCC categories.
Approximate SynonymsGuidance
Alternate terms and clinical phrases that map to this code.
- Psychotic disorder caused by opioid
Instructional NotesGuidance
Instructions from the official ICD-10-CM Tabular List that apply to F11.959: its own notes plus those printed at F11.9 and Chapter 5. A note printed at a category, block or chapter applies to every code under it.
Includes
Further defines, or gives examples of, the content of the category.
- disorders of psychological development
Excludes1
Not coded here: the excluded code is never reported together with this one, unless the two conditions are unrelated.
Excludes2
Not included here: the excluded condition is not part of this code, but a patient may have both, so both codes may be reported.
Source: CMS ICD-10-CM Tabular List. How to read instructional notes.
Referenced in Other NotesGuidance
Instructional notes printed at other codes that name F11.959, its category, or a range that includes it.
Excludes1 2
These codes carry an Excludes1 note naming F11.959: they are not reported together with it, unless the two conditions are unrelated.
Excludes2 1
These codes carry an Excludes2 note naming F11.959: its condition is not part of those codes, and both may be reported when the patient has both.
Use Additional Code 1
These codes say to use an additional code from the note, and F11.959 is one of the codes named.
Index to Diseases and InjuriesGuidance
Alphabetical index entries that point to this code.
Disorder (of) See Also: Disease;
Clinical ClassificationClinical
AHRQ’s CCSR groups this code into broader clinical categories.
Clinical InformationClinical
Opioid-Related Disorders
disorders related to or resulting from abuse or misuse of opioids.
Patient EducationClinical
Opioids and Opioid Use Disorder (OUD)
Opioids, sometimes called narcotics, are a type of drug. They include strong prescription pain relievers such as oxycodone, hydrocodone, fentanyl, and tramadol. The illegal drug heroin is also an opioid. Some opioids are made from the opium plant, and others are synthetic (man-made).
The full article covers:
- What are opioids?
- What are the side effects and risks of opioids?
- What is opioid use disorder (OUD)?
- How are opioid use disorder (OUD) and opioid overdose treated?
- How can I prevent problems when taking prescription opioids?
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert F11.959 to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code HistoryHistory
Questions About F11.959Overview
Is F11.959 a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report opioid use, unspecified with opioid-induced psychotic disorder, unspecified on HIPAA-covered claims from October 1, 2026 through September 30, 2027.
What MS-DRG does F11.959 group to?
When opioid use, unspecified with opioid-induced psychotic disorder, unspecified is the principal diagnosis on an inpatient stay, it groups to MS-DRG 894, 897, 895, 896, with relative weights from 0.6272 to 1.6610 depending on complications. Higher weights mean higher Medicare reimbursement.
Can F11.959 be reported with a code from F11.1?
Not as a rule. The Excludes1 note at F11.9, which applies to F11.959, lists "opioid abuse (F11.1-)". An Excludes1 note means the excluded code is never reported together with this one; the only exception is when the two conditions are unrelated to each other (Official Guidelines, Section I.A.12.a).
What is the ICD-9 equivalent of F11.959?
Under the General Equivalence Mappings, opioid use, unspecified with opioid-induced psychotic disorder, unspecified converts to ICD-9-CM 292.89 (drug mental disorder NEC). The mapping is approximate, so confirm the match fits the documentation.
What HCC is F11.959?
F11.959 (opioid use, unspecified with opioid-induced psychotic disorder, unspecified) maps to CMS-HCC Category 135 (Drug Use with Psychotic Complications), commonly written as HCC 135, in the CMS-HCC V28 model used for Medicare Advantage risk adjustment in payment year 2027. It mapped to HCC 54 under the retired V24 model. It also maps in the PACE (CMS-HCC V22), ESRD (V21), and ESRD (V24) models. It does not map to any RxHCC in the Part D prescription drug model.
Does F11.959 risk-adjust for Medicare Advantage payment?
Yes. When documented and reported on a Medicare Advantage encounter, F11.959 adds a risk adjustment factor of about 0.424 to the beneficiary's RAF score for a community, non-dual, aged enrollee (published V28 weights range from 0.297 to 1.181 depending on the payment segment). HCC 135 sits at the top of its hierarchy, so no other condition category supersedes it. See the full factor table on the HCC 135 category page.
