I26.99
BillableOther 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 I26.99 an HCC code?
Yes. I26.99 maps to Deep Vein Thrombosis and Pulmonary Embolism 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 I26.99
For I26.99to 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 I26.99 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
I26.99 is the ICD-10-CM diagnosis code for other pulmonary embolism without acute cor pulmonale. A blood clot or other material in the lungs that does not fit other specific categories and does not cause immediate heart failure. I26.99 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, I26.99 maps to Deep Vein Thrombosis and Pulmonary Embolism (HCC 267) with a community, non-dual, aged base RAF weight of 0.294. Under the older CMS-HCC V24 model, I26.99 maps to Vascular Disease with Complications (HCC 107) with a community, non-dual, aged base RAF weight of 0.383. 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.
Use as a catch-all only when the specific type of PE is not clearly documented. Because I26.99 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 I26.99 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use as a catch-all only when the specific type of PE is not clearly documented
- •Review documentation carefully to determine if a more specific I26.9x code applies
Clinical Significance
This code captures other types of pulmonary embolism not specifically classified elsewhere, representing significant acute vascular events. Pulmonary embolism is a leading cause of preventable hospital death and indicates complex vascular disease requiring anticoagulation and monitoring. Accurate coding ensures appropriate risk stratification.
Documentation Requirements
- ✓Provider documentation of pulmonary embolism diagnosis
- ✓Specification that the embolism type does not fit other specific I26 subcategories
- ✓Absence of acute cor pulmonale documented
- ✓Diagnostic confirmation (CT pulmonary angiography, V/Q scan, or clinical criteria)
- ✓Documentation of treatment plan (anticoagulation, thrombolytics)
Commonly Confused Codes
- •I26.92 — Saddle embolus without acute cor pulmonale; use when saddle-type embolus is specifically documented
- •I26.96 — Fat embolism of pulmonary artery; use when fat particles are the embolic material
- •I26.09 — Other pulmonary embolism with acute cor pulmonale; use when right heart failure is present
- •I27.82 — Chronic pulmonary embolism; use for long-standing unresolved clots, not acute events