I26.92
BillableSaddle embolus of pulmonary artery without acute cor pulmonale
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is I26.92 an HCC code?
Yes. I26.92 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 I26.92
For I26.92to 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 I26.92 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
I26.92 is the ICD-10-CM diagnosis code for saddle embolus of pulmonary artery without acute cor pulmonale. A large blood clot that straddles the main pulmonary artery branches, blocking blood flow to both lungs, without causing immediate heart failure. I26.92 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, I26.92 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, I26.92 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.
Saddle embolus is a specific anatomical location; confirm imaging documentation supports this finding. Because I26.92 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 I26.92 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Saddle embolus is a specific anatomical location; confirm imaging documentation supports this finding
- •This is a high-risk presentation; verify acute cor pulmonale is not present before coding
Clinical Significance
A saddle embolus at the pulmonary artery bifurcation without acute cor pulmonale describes a large centrally located thrombus that has not yet caused right heart failure. Despite the absence of cor pulmonale, saddle emboli are inherently high-risk due to their central location and the potential for rapid hemodynamic deterioration. These patients require close monitoring, as the transition to cor pulmonale can occur suddenly.
Documentation Requirements
- ✓CT pulmonary angiography confirming thrombus straddling the main pulmonary artery bifurcation
- ✓Documentation that acute cor pulmonale is NOT present — normal right ventricular function and pressures
- ✓Hemodynamic stability documented at the time of diagnosis
- ✓Risk stratification and monitoring plan given the high-risk embolic location
- ✓Anticoagulation and treatment plan with consideration for escalation if clinical deterioration occurs
Commonly Confused Codes
- •I26.02 — Saddle embolus WITH acute cor pulmonale; same location but with right heart failure
- •I26.99 — Other PE without cor pulmonale; non-saddle location PE
- •I26.93 — Single subsegmental PE without cor pulmonale; much smaller embolic burden
- •I26.90 — Septic PE without cor pulmonale; infectious etiology