I26.93
BillableSingle subsegmental thrombotic 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 I26.93 an HCC code?
Yes. I26.93 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 I26.93
For I26.93to 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 I26.93 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
I26.93 is the ICD-10-CM diagnosis code for single subsegmental thrombotic pulmonary embolism without acute cor pulmonale. A single small blood clot in the tiniest branches of the pulmonary artery without causing immediate heart failure. I26.93 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, I26.93 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, I26.93 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.
Subsegmental PE is the smallest classification; ensure documentation specifies single versus multiple. Because I26.93 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 I26.93 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Subsegmental PE is the smallest classification; ensure documentation specifies single versus multiple
- •Verify acute cor pulmonale is absent; if present, use appropriate I26.0x code
Clinical Significance
Single subsegmental thrombotic pulmonary embolism without acute cor pulmonale represents a small peripheral clot in a single subsegmental pulmonary artery branch. The clinical significance of isolated subsegmental PE is debated, as some may represent false positives on CT angiography. Treatment decisions depend on clinical context — some subsegmental PEs in low-risk patients may be monitored rather than anticoagulated per current guidelines.
Documentation Requirements
- ✓CT pulmonary angiography confirming a single subsegmental filling defect
- ✓Documentation that only one subsegmental artery is involved
- ✓Confirmation that acute cor pulmonale is absent
- ✓Clinical risk assessment for VTE and bleeding risk
- ✓Treatment decision documented — anticoagulation vs surveillance with rationale
Commonly Confused Codes
- •I26.94 — Multiple subsegmental thrombotic PE without cor pulmonale; more than one subsegmental vessel involved
- •I26.92 — Saddle embolus without cor pulmonale; much larger, centrally located embolus
- •I26.09 — Other PE with acute cor pulmonale; includes cor pulmonale component
- •I26.99 — Other PE without cor pulmonale; for non-subsegmental, non-specific PE types