I26.90
BillableSeptic pulmonary embolism without acute cor pulmonale
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is I26.90 an HCC code?
Yes. I26.90 maps to Vascular Disease under the CMS-HCC V28 risk adjustment model (and Vascular Disease with Complications 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 I26.90
For I26.90to 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 I26.90 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
I26.90 is the ICD-10-CM diagnosis code for septic pulmonary embolism without acute cor pulmonale. A blood clot containing bacteria that travels to the lungs, typically from an infection elsewhere in the body, without causing immediate heart failure. I26.90 sits in the ICD-10-CM chapter for diseases of the circulatory system (i00-i99), within the section covering pulmonary heart disease and diseases of pulmonary circulation (i26-i28).
Under the CMS-HCC V28 risk adjustment model, I26.90 maps to Vascular Disease (HCC 267) with a community, non-dual, aged base RAF weight of 0.356. Under the older CMS-HCC V24 model, I26.90 maps to Vascular Disease with Complications (HCC 107) with a community, non-dual, aged base RAF weight of 0.450. 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.
Verify documentation confirms septic origin; look for concurrent infection codes. Because I26.90 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 I26.90 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify documentation confirms septic origin; look for concurrent infection codes
- •Ensure acute cor pulmonale is NOT documented; if present, use I26.01 instead
Clinical Significance
Septic pulmonary embolism without acute cor pulmonale represents infected embolic material reaching the pulmonary vasculature without causing right heart failure. While the absence of cor pulmonale suggests a less hemodynamically severe presentation, septic emboli carry significant morbidity due to the infectious component, including risk of lung abscess formation, empyema, and persistent bacteremia. Source control and prolonged antibiotic therapy are essential.
Documentation Requirements
- ✓Imaging evidence of pulmonary embolism
- ✓Documentation of infectious/septic etiology of the emboli — source identification (endocarditis, infected catheter, septic thrombophlebitis)
- ✓Confirmation that acute cor pulmonale is NOT present — normal right heart function on echocardiography
- ✓Blood culture results and antimicrobial sensitivity data
- ✓Source control measures and antibiotic treatment plan
Code First
- underlying infection
Commonly Confused Codes
- •I26.01 — Septic pulmonary embolism WITH acute cor pulmonale; same etiology but with right heart failure
- •I26.99 — Other pulmonary embolism without acute cor pulmonale; non-septic thrombotic PE
- •J85.1 — Abscess of lung with pneumonia; potential complication of septic emboli
- •I33.0 — Acute endocarditis; common source of septic emboli