I26.96
BillableFat 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 I26.96 an HCC code?
Yes. I26.96 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 I26.96
For I26.96to 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 I26.96 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
I26.96 is the ICD-10-CM diagnosis code for fat embolism of pulmonary artery without acute cor pulmonale. Fat particles that travel to the lungs, typically from bone fractures or orthopedic trauma, without causing immediate heart failure. I26.96 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, I26.96 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, I26.96 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.
Look for documentation of recent trauma, fracture, or orthopedic procedure. Because I26.96 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 I26.96 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Look for documentation of recent trauma, fracture, or orthopedic procedure
- •Fat embolism syndrome may have additional manifestations; code those separately if documented
Clinical Significance
Fat embolism of pulmonary vessels is a serious complication typically seen after long bone fractures or orthopedic procedures. It represents significant vascular disease complexity that increases resource utilization and mortality risk. Accurate capture is critical for reflecting the true acuity of trauma patients.
Documentation Requirements
- ✓Documented diagnosis of fat embolism affecting pulmonary artery
- ✓Clinical presentation (dyspnea, tachycardia, petechial rash, neurological changes)
- ✓Absence of acute cor pulmonale explicitly stated or implied
- ✓Precipitating event documented (fracture, orthopedic surgery, trauma)
- ✓Diagnostic confirmation (imaging, clinical criteria such as Gurd criteria)
Code First
Commonly Confused Codes
- •I26.92 — Saddle embolus of pulmonary artery without acute cor pulmonale; saddle embolus is a thrombus, not fat
- •I26.99 — Other pulmonary embolism without acute cor pulmonale; use when embolism type is not fat-specific
- •I26.02 — Saddle embolus of pulmonary artery with acute cor pulmonale; includes right heart failure
- •T79.1XXA — Fat embolism (traumatic); this is an injury code, not a circulatory disease code