J81.0 ICD-10-CM Code: Acute pulmonary edema
J81.0 maps to CMS-HCC V28 213. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · HCC Buddy coding tools
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FY 2026 Apr update / Diseases of the respiratory system (J00-J99) / Other respiratory diseases principally affecting the interstitium (J80-J84)
J81.0
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceAcute pulmonary edema
Sudden buildup of fluid in the lungs that develops quickly, usually due to heart failure or other acute conditions, causing severe breathing difficulty.
Buddy Insight
Acute pulmonary edema represents a medical emergency where rapid fluid accumulation in the lungs causes severe respiratory compromise, most commonly from acute decompensated heart failure.
CMS-HCC V28
MappedHCC 213
Coefficient HCC 213: 0.370 (Community Non-Dual Aged (CNA))
CMS-HCC V24
HistoricalHistorical
Not used for CY2026 payment
ACA/HHS
MappedHCC 127
Code-level coefficient reference
ESRD/PACE
MappedHCC 84
Code-level coefficient reference
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
Official- Acute edema of lung
Excludes 2
Official- certain conditions originating in the perinatal period (P04-P96)Inherited from J00-J99
- certain infectious and parasitic diseases (A00-B99)Inherited from J00-J99
- complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from J00-J99
- congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)Inherited from J00-J99
- endocrine, nutritional and metabolic diseases (E00-E88)Inherited from J00-J99
- injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from J00-J99
- neoplasms (C00-D49)Inherited from J00-J99
- smoke inhalation (T59.81-)Inherited from J00-J99
- symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from J00-J99
Related Codes
Includes
OfficialNo Includes notes are included in this display for J81.0. Check the code and parent instructions in the Code Book.
Excludes 1
Official- chemical (acute) pulmonary edema (J68.1)Inherited from J81
- hypostatic pneumonia (J18.2)Inherited from J81
- passive pneumonia (J18.2)Inherited from J81
- pulmonary edema due to external agents (J60-J70)Inherited from J81
- pulmonary edema with heart disease NOS (I50.1)Inherited from J81
- pulmonary edema with heart failure (I50.1)Inherited from J81
Code First
OfficialNo Code First sequencing instructions are included in this display for J81.0. Check the code and parent instructions in the Code Book.
Use Additional
Official- code, where applicable, to identify:Inherited from J00-J99, J81
- exposure to environmental tobacco smoke (Z77.22)Inherited from J00-J99, J81
- exposure to tobacco smoke in the perinatal period (P96.81)Inherited from J00-J99, J81
- history of tobacco dependence (Z87.891)Inherited from J00-J99, J81
- occupational exposure to environmental tobacco smoke (Z57.31)Inherited from J00-J99, J81
- tobacco dependence (F17.-)Inherited from J00-J99, J81
- tobacco use (Z72.0)Inherited from J00-J99, J81
- code to identify:Inherited from J00-J99, J81
Code Also
OfficialNo Code Also instructions are included in this display for J81.0. Check the code and parent instructions in the Code Book.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →
Is J81.0 an HCC code?
Yes. J81.0 (Acute pulmonary edema) maps to HCC 213, Cardio-Respiratory Failure and Shock under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.370. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.
Coder answer: J81.0 is billable and maps to V28 HCC 213, Cardio-Respiratory Failure and Shock. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- J81.0
- Description
- Acute pulmonary edema
- HCC (V28)
- HCC 213 — Cardio-Respiratory Failure and Shock
- RAF reference coefficient
- 0.370
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. Weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.
Work J81.0 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →
MEAT review for J81.0
For J81.0, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.
- 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
Coder workflow notes
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What This Code Means
J81.0 is the ICD-10-CM diagnosis code for acute pulmonary edema. Sudden buildup of fluid in the lungs that develops quickly, usually due to heart failure or other acute conditions, causing severe breathing difficulty. J81.0 sits in the ICD-10-CM chapter for diseases of the respiratory system (j00-j99), within the section covering other respiratory diseases principally affecting the interstitium (j80-j84).
Under the CMS-HCC V28 risk adjustment model, J81.0 maps to Cardio-Respiratory Failure and Shock (HCC 213) with a source-labeled community, non-dual, aged reference coefficient of 0.370. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.
Always document the underlying cause (typically acute decompensated heart failure) with an additional code. For J81.0, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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, source-labeled coefficient references, and MEAT documentation criteria for J81.0 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Always document the underlying cause (typically acute decompensated heart failure) with an additional code
- •Distinguish from chronic pulmonary edema (J81.1) by confirming the acute onset in the medical record
Clinical Significance
Acute pulmonary edema represents a medical emergency where rapid fluid accumulation in the lungs causes severe respiratory compromise, most commonly from acute decompensated heart failure. It is critically important for risk adjustment because it indicates an acute high-acuity condition requiring emergency treatment and often ICU-level care.
Documentation Requirements
- ✓Documentation of acute onset of pulmonary edema symptoms (dyspnea, orthopnea, pink frothy sputum)
- ✓Chest imaging confirming pulmonary edema (bilateral alveolar infiltrates, Kerley B lines, pleural effusions)
- ✓Underlying cause documented (acute heart failure, volume overload, acute MI, renal failure, etc.)
- ✓Oxygen saturation and blood gas results
- ✓BNP/NT-proBNP levels if cardiogenic
- ✓Treatment provided (diuretics, vasodilators, CPAP/BiPAP, intubation if needed)
- ✓Clinical differentiation from ARDS if non-cardiogenic
Commonly Confused Codes
- •J81.1 (Chronic pulmonary edema): acute sudden onset vs. chronic/recurrent; significantly different clinical urgency
- •J80 (Acute respiratory distress syndrome): non-cardiogenic bilateral infiltrates vs. cardiogenic pulmonary edema
- •I50.21 (Acute systolic heart failure): the underlying cardiac cause, not the pulmonary manifestation
- •J68.1 (Pulmonary edema due to chemicals): chemical-induced vs. cardiogenic/volume-related