ICD-10 F11.20
Billable / Specific HCC v28: 55 CCOpioid dependence, uncomplicated
About ICD-10-CM F11.20
ICD-10-CM code F11.20 represents Opioid dependence, uncomplicated. This is a billable/specific code in the Mental, Behavioral, and Neurodevelopmental chapter (block F11). The 2026 edition of ICD-10-CM F11.20 became effective on October 1, 2025.
Coding Tips for F11.20
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
F11.20 is a CMS-HCC v28 risk-adjustment code (category 55). To count for the patient Risk Adjustment Factor (RAF), document the diagnosis with MEAT language each calendar year: Monitored, Evaluated, Assessed, Treated. A diagnosis on the problem list alone does not satisfy CMS RADV audit standards. Include the diagnosis in the assessment with current status and current treatment plan.
F11.20 is designated CC for MS-DRG grouping. On inpatient claims, this code can shift the DRG to the with-CC variant when documented as a present-on-admission secondary diagnosis. Hospital CDI programs flag CC opportunities during chart review. Failure to capture this code may leave 30 to 80 percent of the inpatient stay revenue unrealized.
Inclusion Terms / Approximate Synonyms
Clinical terms and conditions classified under F11.20. Per CMS ICD-10-CM Tabular 2026.
- Opioid use disorder, moderate
- Opioid use disorder, severe
Medicare Advantage HCC Impact
Capture this diagnosis annually for accurate risk adjustment. Missed HCC captures are the #1 revenue leak in Medicare Advantage risk programs.
Inpatient DRG Impact, CC
code Opioid dependence, uncomplicated. As a Complication/Comorbidity (CC), this contributes to DRG severity adjustment when documented alongside the principal diagnosis.
Medicare LCD Coverage for F11.20
Local Coverage Determinations (LCDs) from CMS MACs that list F11.20 as a covered diagnosis.
Showing top 10 of 465 total . Click a CPT for full coverage scope.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing F11.20.
1 Cigna
5 Medicare
CPT Codes Commonly Billed with F11.20
Procedures frequently paired with this diagnosis based on PayerReady's Dx↔Px linkage data.
- 90837 Psychotherapy 60 min — same as 90834 plus substance use disorders, severe depression Psychiatry
- 90791 Psychiatric diagnostic evaluation — any mental health dx for initial assessment, suicidal ideation, hallucinations, antisocial behavior Psychiatry
- 90792 Psychiatric eval with medical services — schizophrenia, bipolar, MDD, anxiety, personality disorder, ASD, ADHD, substance use Psychiatry
- 90836 Psychotherapy 45 min add-on to E/M — anxiety, depression, PTSD, bipolar, OCD, BPD, substance use Psychiatry
- 96121 CMS LCD: Billing and Coding: Psychiatric Partial Hospitalization Programs CMS LCD
- 96137 CMS LCD: Billing and Coding: Psychiatric Partial Hospitalization Programs CMS LCD
- 96116 CMS LCD: Billing and Coding: Psychiatric Partial Hospitalization Programs CMS LCD
- 96132 CMS LCD: Billing and Coding: Psychiatric Partial Hospitalization Programs CMS LCD
- 90838 CMS LCD: Billing and Coding: Psychiatric Partial Hospitalization Programs CMS LCD
- G0177 CMS LCD: Billing and Coding: Psychiatric Partial Hospitalization Programs CMS LCD
Convert F11.20 to ICD-9-CM
Per CMS General Equivalence Mappings (GEMs), useful for legacy data review and historical claim analysis.
| ICD-10 | ICD-9 | Mapping Flags |
|---|---|---|
| F11.20 | 30400 | 10000 |
| F11.20 | 30401 | 10000 |
| F11.20 | 30402 | 10000 |
Flags format (5 digits): Approximate · No Map · Combination · Scenario · Choice List. Source: CMS 2017 GEMs (final version).
Codes Adjacent To F11.20
Other codes in section F10-F19 (Mental and behavioral disorders due to psychoactive substance use).
ICD-10 F11.20, Billing FAQ
Is ICD-10 code F11.20 billable? +
Yes, F11.20 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
What other names or terms map to F11.20? +
ICD-10 F11.20 includes: Opioid use disorder, moderate; Opioid use disorder, severe.
Does F11.20 affect Medicare Advantage HCC risk adjustment? +
Yes. F11.20 maps to CMS-HCC v28 category 55. Capture this diagnosis annually for accurate Medicare Advantage risk score.
Is F11.20 a CC or MCC for inpatient DRG? +
Yes, this code is designated as CC. Documenting as a secondary diagnosis on inpatient claims can shift the DRG to a higher-weighted category.
What CPT codes are commonly billed with F11.20? +
Procedures frequently paired with F11.20 include: 90837, 90791, 90792, 90836, 96121.
What ICD-9 codes does F11.20 map to? +
Per CMS GEMs, F11.20 maps to ICD-9 codes: 30400, 30401, 30402. Useful for legacy data review and historical claim analysis.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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