P26.1
BillableMassive pulmonary hemorrhage originating in the perinatal period
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is P26.1 an HCC code?
Yes. P26.1 maps to Cardio-Respiratory Failure and Shock under the CMS-HCC V28 risk adjustment model.
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 P26.1
For P26.1to 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 P26.1 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
P26.1 is the ICD-10-CM diagnosis code for massive pulmonary hemorrhage originating in the perinatal period. Severe, life-threatening bleeding into the lungs of a newborn during the perinatal period, often causing respiratory failure and shock. P26.1 sits in the ICD-10-CM chapter for certain conditions originating in the perinatal period (p00-p96), within the section covering respiratory and cardiovascular disorders specific to the perinatal period (p19-p29).
Under the CMS-HCC V28 risk adjustment model, P26.1 maps to Cardio-Respiratory Failure and Shock (HCC 213) with a community, non-dual, aged base RAF weight of 0.000. P26.1 was not retained as a payment HCC under the older V24 model, so V28 introduced or recategorized it during the 2024–2026 phase-in. 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 serious condition requiring intensive care; document treatment interventions and clinical response. Because P26.1 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 P26.1 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This is a serious condition requiring intensive care; document treatment interventions and clinical response
- •Identify and code any underlying causes such as infection, coagulopathy, or pulmonary hypoplasia
Clinical Significance
Massive pulmonary hemorrhage in newborns is a life-threatening emergency requiring immediate intervention and intensive care management. This condition carries high morbidity and mortality risk, often necessitating mechanical ventilation and blood product replacement therapy.
Documentation Requirements
- ✓Documentation of massive bleeding into lung parenchyma
- ✓Evidence of hemodynamic compromise or shock
- ✓Confirmation of perinatal period onset
- ✓Gestational age and birth weight
- ✓Chest imaging showing extensive pulmonary hemorrhage
- ✓Blood gas analysis results
- ✓Ventilator support requirements
- ✓Blood transfusion needs and hematocrit levels