I26.95
BillableCement embolism 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 I26.95 an HCC code?
Yes. I26.95 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 I26.95
For I26.95to 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 I26.95 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
I26.95 is the ICD-10-CM diagnosis code for cement embolism of pulmonary artery without acute cor pulmonale. A blood clot made of bone cement that travels to the lungs, typically from orthopedic surgery, without causing immediate heart failure. I26.95 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, I26.95 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, I26.95 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.
This is a rare complication of orthopedic procedures; look for recent surgery documentation. Because I26.95 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 I26.95 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This is a rare complication of orthopedic procedures; look for recent surgery documentation
- •Verify cement embolism is specifically documented; do not assume from procedure alone
Clinical Significance
Cement embolism of the pulmonary artery without acute cor pulmonale is an iatrogenic complication of vertebroplasty or kyphoplasty where bone cement migrates to the pulmonary vasculature but has not caused right heart failure. While hemodynamically less severe than cases with cor pulmonale, cement emboli in the lungs are permanent foreign bodies that may cause local inflammation and long-term pulmonary complications. Surveillance for delayed complications is essential.
Documentation Requirements
- ✓Recent vertebroplasty, kyphoplasty, or other cement-utilizing procedure
- ✓CT imaging confirming hyperdense cement material in the pulmonary vasculature
- ✓Documentation that acute cor pulmonale is NOT present — normal right heart function
- ✓Temporal relationship to the surgical procedure documented
- ✓Follow-up and surveillance plan for long-term pulmonary effects
Code First
- complication of other artery following a procedure (T81.718)
Commonly Confused Codes
- •I26.03 — Cement embolism WITH acute cor pulmonale; same etiology but with right heart failure
- •I26.99 — Other PE without cor pulmonale; non-cement thrombotic PE
- •I26.93 — Single subsegmental thrombotic PE without cor pulmonale; thrombotic, not cement material
- •T84.89XA — Complications of internal orthopedic devices; different complication classification