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This Clinical Documentation Guide (CDG) provides AAPC/AHIMA-credentialed coders and CDI specialists with comprehensive coding, clinical, and documentation guidance for pulmonary embolism (PE). Content reflects FY2026 ICD-10-CM guidelines (effective October 1, 2025 – September 30, 2026) and incorporates current clinical, risk-stratification, and MS-DRG reimbursement guidance. Use this guide to ensure accurate diagnosis code assignment, appropriate CDI query triggers, and defensible documentation for PE encounters across inpatient, outpatient, and observation settings.
1. Definition
Pulmonary embolism (PE) is the acute obstruction of one or more pulmonary arteries — or their branches — by a thrombus (most commonly), air, fat, amniotic fluid, tumor fragments, or foreign material. The obstruction increases pulmonary vascular resistance, impairs gas exchange, and, in severe cases, precipitates acute right ventricular (RV) failure. PE is classified along a spectrum from incidental subsegmental clots to massive, immediately life-threatening obstruction, as described by the 2023 AHA/ACC Scientific Statement on Venous Thromboembolism.
PE is the third most common acute cardiovascular condition after myocardial infarction and stroke, with an estimated 300,000–600,000 cases annually in the United States per CDC Blood Clots data. In-hospital mortality for massive PE can exceed 30%, and PE remains the most preventable cause of in-hospital death, according to NHLBI.
Severity stratification — massive (hemodynamic instability), submassive (RV dysfunction without shock), and low-risk — drives clinical management pathways including systemic thrombolysis, catheter-directed therapy, and anticoagulation alone. Accurate documentation of severity, laterality, and associated right heart findings directly impacts MS-DRG assignment and HCC risk adjustment.
Key Subtypes
- Acute PE with acute cor pulmonale: Right heart strain documented by echo, EKG, or clinical findings; captures the highest-severity codes (I26.0x) and maps to HCC 223.
- Saddle PE: Embolus straddling the bifurcation of the main pulmonary artery; associated with highest hemodynamic risk.
- Septic PE: Emboli from an infected thrombus or right-sided endocarditis; requires documentation of infectious source.
- Subsegmental PE (SSPE): Limited to subsegmental arteries; two new FY2025 codes (I26.93, I26.94) now capture single vs. multiple subsegmental PE — a major coding specificity advance.
- Chronic PE: Incompletely resolved acute PE leading to chronic thromboembolic pulmonary hypertension (CTEPH); coded separately as I27.82.
- Obstetric PE: Thromboembolism complicating pregnancy, delivery, or the puerperium; coded from O88.2x with an additional I26.9x code per obstetric sequencing rules.
2. Alternative Terminology
Coders and CDI specialists will encounter multiple terms in clinical documentation that map to the I26 category or related codes. The following table summarizes accepted and colloquial terminology:
| Formal / ICD-10-CM Term | Colloquial / Lay / Alternate Names |
|---|---|
| Pulmonary embolism (PE) | Blood clot in the lung, lung clot, pulmonary clot, PE |
| Acute cor pulmonale | Acute right heart failure (from PE), acute RV strain, acute RV failure |
| Saddle embolus of pulmonary artery | Saddle PE, main PA embolus, bifurcation PE, central PE |
| Septic pulmonary embolism | Infected PE, septic lung embolus, septicopyemic embolism |
| Subsegmental pulmonary embolism | Peripheral PE, small PE, distal PE, incidental PE, SSPE |
| Chronic pulmonary embolism (I27.82) | CTEPH, chronic thromboembolic pulmonary hypertension, chronic PE |
| Venous thromboembolism (VTE) | Blood clot, DVT/PE, thromboembolic disease, thrombotic event |
| Pulmonary thromboembolism | PTE, lung embolism, pulmonary vascular occlusion |
| Massive pulmonary embolism | High-risk PE, hemodynamically significant PE (not a separate ICD-10 code — captured via acute cor pulmonale) |
| Submassive pulmonary embolism | Intermediate-risk PE, RV dysfunction PE (not separately coded; document RV dysfunction/strain for secondary codes) |
| Obstetric thromboembolism | Pregnancy-related PE, peripartum embolism, postpartum blood clot |
Terms like “massive” and “submassive” PE are clinical risk-stratification labels, not ICD-10-CM categories. “Massive” PE is typically coded via the presence of acute cor pulmonale (I26.0x). “Submassive” PE with documented RV dysfunction without cor pulmonale defaults to I26.9x. CDI should query physicians for explicit documentation of acute cor pulmonale when RV strain is noted on echo or EKG.
3. Signs & Symptoms
PE presents across a spectrum from asymptomatic (incidentally found) to cardiovascular collapse. Classic and atypical presentations documented in the medical record support coding and CDI queries per NHLBI PE Symptoms:
Classic Presentation
- Sudden-onset dyspnea (most common symptom — up to 80% of cases)
- Pleuritic chest pain (sharp, worsened by inspiration)
- Hemoptysis (coughing up blood)
- Tachycardia (>100 bpm) and tachypnea
- Hypoxemia / low oxygen saturation
- Unilateral leg swelling, pain, erythema (concurrent DVT)
Massive PE (Hemodynamic Instability)
- Systolic BP <90 mmHg or drop >40 mmHg sustained ≥15 minutes
- Cardiogenic shock or cardiac arrest
- Syncope or near-syncope
- Acute right ventricular failure signs: JVD, RV heave, S3 or S4 gallop
- New right bundle branch block (RBBB) on EKG, S1Q3T3 pattern
Submassive PE (RV Dysfunction Without Shock)
- Echo: RV dilation, hypokinesis, septal flattening (D-sign), McConnell sign
- Elevated troponin I/T (myocardial injury from RV strain)
- Elevated BNP or NT-proBNP (RV pressure overload)
- Borderline or normal BP with tachycardia
Low-Risk / Incidental PE
- Subsegmental PE discovered incidentally on CT performed for another indication
- Minimal or absent symptoms; no hemodynamic compromise
Septic PE — Additional Findings
- Fever, chills, rigors; bacteremia or documented sepsis
- Multiple peripheral cavitary lung lesions on imaging
- Evidence of right-sided endocarditis, IV catheter infection, or septic thrombophlebitis
Tachycardia, hypoxemia, and dyspnea alone do not document acute cor pulmonale — echocardiographic or clinical evidence of acute RV dysfunction is required to code I26.0x. Without explicit documentation from the treating provider, default to I26.9x.
4. Differential Diagnosis
The following conditions share clinical features with PE and must be excluded or documented alongside PE for accurate coding:
| Condition | Key Distinguishing Features | Relevant ICD-10-CM |
|---|---|---|
| Acute myocardial infarction (AMI) | ST changes on EKG, troponin elevation, chest pressure; coronary angiography distinguishes | I21.x–I22.x |
| Pneumonia | Fever, productive cough, consolidation on CXR/CT, leukocytosis | J12–J18.x |
| Pneumothorax | Absent breath sounds, unilateral chest pain, pleural air on CXR | J93.x |
| Aortic dissection | Tearing/ripping chest/back pain, BP differential in arms, widened mediastinum | I71.0x |
| Acute pericarditis | Positional chest pain, friction rub, diffuse ST elevation, PR depression | I30.x |
| Heart failure exacerbation | Bilateral edema, elevated BNP, crackles, known cardiomyopathy; echo differentiates | I50.x |
| Pleuritis / pleurisy | Pleuritic pain without emboli; imaging negative for PE | R09.1, J90 |
| Anxiety / panic disorder | Hyperventilation, no imaging findings; diagnosis of exclusion | F41.0, F41.1 |
| COPD exacerbation | Known COPD, wheezing, prior exacerbation history; V/Q may be indeterminate | J44.1 |
| Right heart failure (non-PE) | Chronic RV dysfunction, known pulmonary hypertension, no new emboli | I50.810, I27.x |
| Deep vein thrombosis (DVT) without PE | Leg swelling/pain only; CTPA negative; DVT confirmed on venous duplex | I82.4xx, I82.6xx |
5. Clinical Indicators for Coders/CDI
The following clinical indicators support PE diagnosis coding and CDI query triggers. Presence of these elements without explicit provider documentation of PE should prompt a CDI query, not an assumption of the diagnosis:
| Clinical Indicator | Coding/CDI Significance |
|---|---|
| CT pulmonary angiography (CTPA) positive for PE | Gold standard diagnostic; confirms PE coding; note bilateral vs. unilateral; saddle vs. lobar/segmental/subsegmental location |
| V/Q scan high-probability result | Supports PE diagnosis when CTPA contraindicated; document results in physician note |
| Echocardiogram: RV dilation, McConnell sign, septal bowing | Supports acute cor pulmonale documentation (I26.0x upgrade); trigger CDI query if not documented by physician |
| Troponin elevation + tachycardia + hypoxemia | Supports submassive/RV dysfunction; query physician for acute cor pulmonale vs. RV strain characterization |
| Systolic BP <90 mmHg, vasopressors, or CPR | Massive PE; document hemodynamic instability; supports acute cor pulmonale coding |
| Initiation of therapeutic anticoagulation or thrombolysis | Confirms clinically significant PE; anticoagulant use → Z79.01 |
| IVC filter placement | Documents anticoagulation contraindication; code filter placement with 37193 |
| Positive lower extremity venous duplex for DVT | Concurrent DVT requires separate I82.4xx code with laterality and acute/chronic |
| Bacteremia / positive blood cultures with IV drug use or catheter | Supports septic PE — query for septic vs. bland PE and infectious source |
| Prior PE history, Factor V Leiden, antiphospholipid syndrome | Supports thrombophilia and Z86.711; code hypercoagulable state (D68.5x, D68.61, D68.62) |
| Pregnancy, postpartum status | Trigger obstetric sequencing — O88.2x principal, I26.9x additional |
| Subsegmental location only on CTPA | FY2025 new codes I26.93 (single) or I26.94 (multiple) — a major specificity opportunity |
When the echocardiogram documents RV dilation, septal flattening, or McConnell sign in a confirmed PE patient — and the physician note does not use the term “acute cor pulmonale” or “RV failure” — initiate a clarification query. The difference between I26.09 (with acute cor pulmonale) vs. I26.99 (without) affects both MS-DRG grouping and HCC assignment (HCC 266 vs. HCC 223).
6. Anatomy & Pathophysiology
Understanding PE pathophysiology supports accurate code selection, CDI queries, and audit defense.
Vascular Anatomy
The pulmonary arterial tree begins at the main pulmonary artery (arising from the right ventricle), which bifurcates at the carina into left and right main pulmonary arteries. Each further divides into lobar arteries (3 right, 2 left), segmental arteries (10 right, 8–9 left), and subsegmental arteries. A saddle embolus straddles the main pulmonary artery bifurcation, obstructing both sides simultaneously — the most hemodynamically devastating location per AHA/ACC 2023 VTE Statement.
Pathophysiology
PE results primarily from the Virchow triad: (1) venous stasis, (2) endothelial injury, and (3) hypercoagulability. DVT — most frequently in the proximal lower extremity veins (iliofemoral segment) — is the precursor to PE in approximately 70–80% of cases. The thrombus propagates proximally, breaks loose, and travels through the right heart into the pulmonary circulation.
Hemodynamic Consequences
- Increased pulmonary vascular resistance (PVR): Mechanical obstruction + hypoxia-mediated vasoconstriction raises afterload on the thin-walled RV.
- RV dilation and dysfunction: The RV, unaccustomed to high afterload, dilates; septal shift (leftward D-sign) reduces LV filling and cardiac output.
- Acute cor pulmonale: Acute RV pressure overload with RV failure — the clinical syndrome documented to assign I26.0x codes. Defined by the ACC as echocardiographic or clinical evidence of acute RV pressure overload.
- Decreased cardiac output → cardiogenic shock in massive PE.
- Impaired gas exchange: V/Q mismatch, alveolar dead space, reflex bronchoconstriction → hypoxemia, hypocapnia.
Subsegmental PE — Clinical Significance
Subsegmental PE (SSPE) involves clot limited to subsegmental arteries without proximal extension. Clinical significance is debated — many SSPE resolve without treatment, particularly in patients with low risk of DVT propagation. The NEJM PEITHO-3 trial data and current AHA guidelines suggest surveillance anticoagulation decisions in SSPE be individualized. The FY2025 addition of I26.93 and I26.94 allows coders to precisely document single vs. multiple SSPE — critical for accurate risk profiling and payer communication.
7. Medication Impact / Treatment
Medications used in PE treatment have direct coding implications for complication tracking, drug codes (HCPCS), and Z-code assignment:
Anticoagulation (Primary Treatment)
- Unfractionated Heparin (UFH): IV bolus + continuous infusion; initial therapy for massive/submassive PE and when thrombolysis is being considered. Coded with J1655 (heparin lock flush — note: continuous infusion billed per unit). Z79.01 (long-term anticoagulant use) applicable for extended treatment.
- Low Molecular Weight Heparin (LMWH): Enoxaparin (J1650 per 10 mg), dalteparin (J1645 per 2,500 IU); preferred bridge or outpatient treatment. Report Z79.01 for long-term use.
- Fondaparinux: Factor Xa inhibitor; J1652 per 0.5 mg; alternative for HIT patients.
- Direct Oral Anticoagulants (DOACs): Apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), edoxaban (Savaysa) — first-line for most non-massive PE. Billed under Medicare Part D NDC codes, not outpatient HCPCS J-codes; document long-term use with Z79.01. See HCPCS section for Part B exceptions.
- Warfarin: INR-monitored oral anticoagulant; less common since DOAC advent; Z79.01.
Thrombolysis (Systemic)
- Alteplase (tPA): J2997 (per mg); systemic administration for massive PE with hemodynamic collapse; contraindicated in recent surgery/stroke. Monitor for bleeding complications — code any hemorrhagic adverse effect.
- Reteplase: J2998; alternative thrombolytic agent; similar monitoring requirements.
Catheter-Directed Therapy (CDT)
- Low-dose catheter-directed thrombolysis or ultrasound-assisted CDT (EkoSonic/EKOS); typically 10–24 mg tPA over 12–24 hours; coded with CPT 37187 or 37184–37188 based on procedure specifics. Document clinical rationale for CDT selection over systemic therapy.
Vasopressors / Resuscitative Agents
- Norepinephrine, vasopressin, dobutamine for cardiogenic shock complicating massive PE; document shock type and hemodynamic instability to support acute cor pulmonale coding (I26.0x).
Anticoagulation Reversal
- Andexanet alfa (Andexxa) for apixaban/rivaroxaban reversal; idarucizumab (Praxbind) for dabigatran reversal; protamine for heparin reversal — code adverse effects if applicable.
DOACs and Part D billing: Oral apixaban, rivaroxaban, dabigatran, and edoxaban are dispensed under Medicare Part D and billed using NDC codes — not HCPCS J-codes. Do NOT report HCPCS J-codes for oral DOACs. Document Z79.01 (long-term anticoagulant use) for all extended DOAC therapy to support HCC documentation and risk adjustment accuracy.
Preview ends here. The full guide continues with FY2026 ICD-10-CM code sets, CPT surgical coding, MS-DRG mapping, reimbursement guidance, CDI query templates, and an audit checklist — all available to CCO Members.
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8. ICD-10-CM Guidelines (FY2026)
The following official coding guidelines apply to pulmonary embolism per FY2026 ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2025):
Principal Diagnosis Selection
- Acute PE confirmed by imaging is coded first (I26.xx) when it is the condition established after workup to be chiefly responsible for the admission.
- When a patient is admitted for both DVT and PE, either may be sequenced first based on the circumstances of admission (ICD-10-CM Official Guidelines Section II). CDI query is appropriate when provider documentation is ambiguous.
- If the patient is admitted for treatment of PE (e.g., catheter-directed thrombolysis, anticoagulation initiation), PE is the principal diagnosis.
Acute vs. Chronic Distinction
- Acute PE = new or newly diagnosed obstruction with acute symptoms; coded to I26.xx.
- Chronic PE = organized, incompletely resolved thrombus with chronic pulmonary hypertension (CTEPH); coded to I27.82 (Chronic pulmonary embolism) — this code is in category I27 (Other pulmonary heart diseases), not I26. Do not use I26.xx for chronic PE.
- When acute PE is superimposed on chronic PE, code both I26.xx (acute) and I27.82 (chronic).
Acute Cor Pulmonale Documentation Requirement
- Codes I26.01, I26.02, I26.09 require physician documentation of acute cor pulmonale. Echocardiographic evidence alone (RV dilation, RV strain) is NOT sufficient — the provider must document the clinical diagnosis. CDI query is appropriate when echo shows RV dysfunction but documentation is absent.
- “Acute right heart failure,” “acute right ventricular failure,” or “acute RV strain” documented by the provider as a result of PE may support acute cor pulmonale coding — verify with physician query for clinical correlation.
Septic PE — Dual Coding Required
- I26.01 (with acute cor pulmonale) or I26.90 (without acute cor pulmonale) requires an additional code for the infectious organism or underlying septic source (e.g., endocarditis, IV catheter infection, septic thrombophlebitis). Query physician to document the source organism/site.
FY2025 Subsegmental PE Codes (Effective Oct 1 2024, FY2026 Active)
- I26.93 — Single subsegmental pulmonary embolism without acute cor pulmonale
- I26.94 — Multiple subsegmental pulmonary emboli without acute cor pulmonale
- These codes are NEW as of FY2025 (effective October 1, 2024) and remain active for FY2026. Assign when CT or V/Q imaging documents PE limited to subsegmental arteries only.
- If any embolus is at the segmental level or above, assign the appropriate I26.9x or I26.0x code — do not use I26.93/I26.94.
Obstetric PE Sequencing (O88.2x)
- When PE occurs during pregnancy, delivery, or the puerperium, sequence O88.2x as principal diagnosis, with an additional I26.9x code for the PE type. The seventh character on O88.2x indicates the trimester or postpartum status.
- Do not code I26.xx as principal for obstetric patients — obstetric codes from Chapter 15 take precedence per ICD-10-CM guidelines.
DVT and PE Concurrent Coding
- When DVT is documented concurrently with acute PE, assign both the I26.xx PE code and the appropriate I82.4xx (lower extremity DVT) or I82.6xx (upper extremity) code. Laterality and acute/chronic status are required for I82.4xx codes.
- DVT codes require the full character set: I82.4 (acute lower extremity by site), I82.6 (acute upper extremity). For example, I82.401 (DVT, right femoral), I82.411 (DVT, right tibial) — see ICD-10Data I82 category for full code selection.
Personal History of PE (Z86.711)
- Assign Z86.711 when PE has been resolved and the patient presents for an unrelated reason. This code captures prior PE without ongoing anticoagulation implication.
- Do NOT assign I26.xx for resolved PE — Z86.711 is appropriate.
- If the patient remains on anticoagulants for secondary prevention, also code Z79.01 (long-term anticoagulant use).
Thrombophilia and Hypercoagulable States
- D68.51 — Factor V Leiden mutation (Activated protein C resistance); code as additional diagnosis when documented and clinically relevant to the PE.
- D68.59 — Other primary thrombophilia (protein C/S deficiency, prothrombin gene mutation).
- D68.61 — Antiphospholipid syndrome; D68.62 — Lupus anticoagulant syndrome. Code when documented as contributing to the thromboembolic event.
9. ICD-10-CM Code Set (FY2026)
Primary PE Codes — Category I26
| Code | Description | Notes / MS-DRG Impact |
|---|---|---|
| I26.01 | Septic pulmonary embolism with acute cor pulmonale | Requires documented infectious source; HCC 223 (Cor Pulmonale); MCC-level severity; add organism/source code |
| I26.02 | Saddle embolus of pulmonary artery with acute cor pulmonale | Embolus at PA bifurcation; clinically massive; HCC 223; MCC-level; highest-acuity PE code |
| I26.09 | Other pulmonary embolism with acute cor pulmonale | Lobar, segmental PE with documented acute cor pulmonale; HCC 223; MCC-level |
| I26.90 | Septic pulmonary embolism without acute cor pulmonale | Requires documented septic source; HCC 266; add infectious source code |
| I26.92 | Saddle embolus of pulmonary artery without acute cor pulmonale | Saddle PE without documented RV failure; HCC 266; CC-level |
| I26.93 | Single subsegmental pulmonary embolism without acute cor pulmonale [NEW FY2025] | Single SSPE; major FY2025 specificity addition; HCC 266; may be CC or non-CC per MS-DRG grouper |
| I26.94 | Multiple subsegmental pulmonary emboli without acute cor pulmonale [NEW FY2025] | Multiple SSPE; similar clinical profile to I26.93; HCC 266; document number/distribution from CTPA report |
| I26.99 | Other pulmonary embolism without acute cor pulmonale | Default acute PE without specified subtype or acute cor pulmonale; HCC 266; CC-level |
Chronic PE and Related Codes
| Code | Description | Notes |
|---|---|---|
| I27.82 | Chronic pulmonary embolism | CTEPH; HCC 223 (Cor Pulmonale/Pulmonary Hypertension); code in I27 category — NOT I26; see ICD-10Data |
| O88.21 | Thromboembolism in pregnancy, first trimester | Obstetric PE; principal Dx; add I26.9x |
| O88.22 | Thromboembolism in pregnancy, second trimester | Obstetric PE; add I26.9x |
| O88.23 | Thromboembolism in pregnancy, third trimester | Obstetric PE; add I26.9x |
| O88.219 | Thromboembolism in pregnancy, unspecified trimester | Use when trimester not documented |
| O88.82 | Other thromboembolism in childbirth | During delivery encounter |
| O88.83 | Other thromboembolism in the puerperium | Within 6 weeks postpartum |
Associated / Concurrent Diagnosis Codes
| Code | Description | Usage Notes |
|---|---|---|
| I82.4xx | Acute DVT of lower extremity (by site + laterality) | Full code required: e.g., I82.401 (right femoral), I82.411 (right tibial), I82.421 (right iliac), I82.431 (right popliteal), I82.491 (other right lower extremity); bilateral codes available; see DVT CDG / I82 category |
| I82.6xx | Acute embolism and thrombosis of upper extremity veins | I82.601/I82.602 (right/left upper extremity); add laterality for upper extremity DVT concurrent with PE |
| Z86.711 | Personal history of pulmonary embolism | For resolved PE only; no HCC mapping; code Z79.01 if on ongoing anticoagulants |
| Z79.01 | Long-term (current) use of anticoagulants | Code whenever patient is on LMWH, warfarin, DOACs, or heparin for extended PE treatment |
| D68.51 | Activated protein C resistance (Factor V Leiden) | Hereditary hypercoagulability contributing to PE; code as additional when documented by provider |
| D68.59 | Other primary thrombophilia | Protein C deficiency, protein S deficiency, antithrombin III deficiency, prothrombin gene mutation |
| D68.61 | Antiphospholipid syndrome | APS-associated PE; code when APS is documented contributor |
| D68.62 | Lupus anticoagulant syndrome | LAC-associated hypercoagulability; code as additional |
| T80.0XXA | Air embolism following infusion/transfusion (initial encounter) | Iatrogenic air embolism; not coded to I26; external cause codes apply |
DVT laterality and acuity are required characters. I82.4 codes without full specificity (laterality + vein site + acute/chronic) will fail edit/scrubbing. I82.40 (unspecified) is valid but represents a documentation gap — CDI should query for specific site and laterality when the duplex report provides this information but the provider note is silent. Using I82.40 when the chart contains laterality is a coder error, not a physician documentation gap.
10. Indexing
Use the FY2026 ICD-10-CM Alphabetic Index and Tabular List to locate PE codes. Key index pathways include:
| Index Term / Lead Term | Subterm(s) | Code Result |
|---|---|---|
| Embolism, pulmonary | — with acute cor pulmonale; septic | I26.01 |
| Embolism, pulmonary | — with acute cor pulmonale; saddle | I26.02 |
| Embolism, pulmonary | — with acute cor pulmonale; other | I26.09 |
| Embolism, pulmonary | — without acute cor pulmonale; septic | I26.90 |
| Embolism, pulmonary | — without acute cor pulmonale; saddle | I26.92 |
| Embolism, pulmonary | — subsegmental; single | I26.93 |
| Embolism, pulmonary | — subsegmental; multiple | I26.94 |
| Embolism, pulmonary | — without acute cor pulmonale; other | I26.99 |
| Embolism, pulmonary, chronic | — | I27.82 |
| Thromboembolism — see Embolism | obstetric, in pregnancy | O88.21x–O88.23x |
| Cor pulmonale, acute | — | I26.09 (or I26.01/I26.02 if septic/saddle) |
| History (personal), pulmonary embolism | — | Z86.711 |
| Resistance, protein C (activated) | — | D68.51 |
| Syndrome, antiphospholipid | — | D68.61 |
The Alphabetic Index may still default to I26.99 for “pulmonary embolism” without modifiers. Always verify in the Tabular to select the correct 5th or 6th character based on documentation. The FY2025 subsegmental codes (I26.93, I26.94) require explicit review of the radiology report — confirm the clot is limited to subsegmental arteries before assigning.
11. CPT (2026)
The following CPT codes apply to PE diagnosis and treatment procedures. All codes reflect CY2026 CPT (AMA):
| CPT Code | Description | Global Period | Notes |
|---|---|---|---|
| 71275 | CT angiography, chest (CTPA) with contrast; includes noncontrast and delayed images | 0 days | Gold standard diagnostic for PE; bilateral pulmonary arteries; documents location (saddle, lobar, segmental, subsegmental) |
| 78451 | Myocardial perfusion imaging, SPECT; single study | 0 days | V/Q scan component; also see 78452–78454 |
| 78452 | Myocardial perfusion imaging, SPECT; multiple studies | 0 days | — |
| 78453 | Pulmonary perfusion imaging; planar | 0 days | V/Q scan — perfusion portion; diagnose PE when CTPA contraindicated (renal insufficiency, contrast allergy) |
| 78454 | Pulmonary perfusion imaging; SPECT | 0 days | Higher sensitivity than planar; used in CTEPH follow-up |
| 93306 | Echocardiography, transthoracic, complete; with spectral Doppler echocardiography | 0 days | Documents RV dilation, RVSP, septal flattening; supports acute cor pulmonale coding; McConnell sign |
| 93355 | Echocardiography, transesophageal (TEE) | 0 days | Used in massive PE or equivocal transthoracic echo; documents RV thrombus, vegetation in septic PE |
| 37184 | Primary percutaneous transluminal mechanical thrombectomy, arterial; initial vessel | 0 days | Catheter-directed thrombectomy for PE; document vessel(s) treated |
| 37185 | Primary percutaneous transluminal mechanical thrombectomy; each additional vessel | 0 days | Add-on to 37184 |
| 37186 | Secondary percutaneous transluminal thrombectomy | 0 days | Repeat thrombectomy same vessel |
| 37187 | Percutaneous transluminal mechanical thrombectomy, venous; initial vessel | 0 days | Pulmonary arteriovenous CDT; may include ultrasound-assisted (EKOS); document thrombolytic agent used |
| 37188 | Percutaneous transluminal mechanical thrombectomy, venous; each additional vessel | 0 days | Add-on to 37187 |
| 32141 | Thoracotomy; with resection-plication of bullae, with or without any pleural procedure | 90 days | Open pulmonary embolectomy (Trendelenburg procedure); used in massive PE refractory to thrombolysis; rare; high-risk surgical intervention |
| 33968 | Removal of intra-aortic balloon assist device | 0 days | CDT catheter removal; verify specificity per operative note — confirm correct CPT for device type |
| 37193 | Repositioning of intravascular vena cava filter, percutaneous | 0 days | IVC filter insertion/retrieval; report 37191 (insert), 37192 (reposition), 37193 (remove); document filter type (retrievable vs. permanent) and indication (anticoagulation contraindication) |
CPT 37187 (venous mechanical thrombectomy) is often confused with 37184 (arterial). For catheter-directed PE therapy through the pulmonary arterial system, confirm whether the operative report documents arterial or venous approach and pharmacomechanical vs. mechanical-only thrombectomy. Ultrasound-assisted CDT (e.g., EKOS device) may have payer-specific coding requirements — verify LCD/NCD applicability.
12. HCPCS (2026)
| HCPCS Code | Description | Typical Use / Notes |
|---|---|---|
| J1645 | Dalteparin sodium injection, per 2,500 IU | LMWH; bridge/extended anticoagulation for PE; subcutaneous; report units per dose administered |
| J1650 | Enoxaparin sodium injection, per 10 mg | Most commonly used LMWH in U.S.; report units per mg administered (e.g., 80 mg = 8 units J1650) |
| J1655 | Tinzaparin sodium injection, per 175 IU/kg | Heparin lock flush alternative LMWH; less common; verify formulary coverage |
| J1652 | Fondaparinux sodium injection, 0.5 mg | Factor Xa inhibitor; used in HIT patients or LMWH allergy; report per 0.5 mg increment |
| J2997 | Alteplase recombinant, 1 mg | tPA systemic thrombolysis for massive PE; report per mg administered (standard 100 mg = 100 units); also used for CDT (low-dose) |
| J2998 | Reteplase, 18.1 mg | Reteplase thrombolytic; less common in PE; verify payer coverage and indication documentation |
| Oral DOACs — Part D NDC Note: Apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), and edoxaban (Savaysa) are oral medications dispensed under Medicare Part D NDC billing — they do NOT have Part B HCPCS J-codes for outpatient administration. In the inpatient setting, these are included in the DRG payment. For outpatient/physician office infusion billing, confirm payer policy. Z79.01 (long-term anticoagulant use) should always be coded with chronic DOAC therapy. | ||
13. AHA Coding Clinic (Recent Guidance)
The following AHA Coding Clinic guidance is relevant to pulmonary embolism coding. Coders and CDI specialists should review current Coding Clinic issues for the most up-to-date official guidance:
| Topic | Coding Clinic Reference / Guidance Summary |
|---|---|
| Acute cor pulmonale with PE | Coding Clinic guidance supports coding acute cor pulmonale (I26.0x) only when the provider explicitly documents the diagnosis. RV dilation on echo alone does not authorize coder assignment of cor pulmonale without physician confirmation. CDI query is appropriate. |
| Septic PE — source documentation | Coding Clinic has addressed infectious PE coding: the source of the septic embolism (e.g., tricuspid valve endocarditis, PICC line infection, septic thrombophlebitis) should be documented and coded in addition to I26.01 or I26.90. |
| Chronic PE (I27.82) vs. acute PE (I26.xx) | Per Coding Clinic, I27.82 is reserved for organized, chronic thrombus with evidence of pulmonary hypertension (CTEPH). Recurrent acute PE in a patient with prior PE history is still coded as I26.xx (acute), not I27.82, unless CTEPH is explicitly documented. |
| Subsegmental PE — FY2025 new codes | Coding Clinic Q1/2025 addressed the new I26.93 and I26.94 codes: assign based on CTPA or V/Q documentation of subsegmental-only involvement. Radiologist/clinician documentation of “subsegmental” is required — coder interpretation of imaging is not sufficient. |
| DVT with PE — sequencing | Coding Clinic guidance: when a patient presents with both acute DVT and PE, sequence PE or DVT as principal diagnosis based on the reason for the visit/admission and circumstances of treatment per ICD-10-CM Official Guidelines Section II, Rule C. |
| Z86.711 — resolved PE | Assign Z86.711 (personal history of PE) only when the PE is fully resolved and no longer being treated as an active condition. Do not assign I26.xx for historical PE without current clinical significance. |
AHA Coding Clinic is the official interpretation authority for ICD-10-CM/PCS coding questions. Always verify the most current Coding Clinic issue via AHA Central Office for any new guidance published after the issuance of this CDG. Guidance above reflects published positions available through FY2026 development.
14. HCC / Risk Adjustment (v28)
HCC mappings below reflect CMS-HCC Model v28 (implemented for 2024 plan years and phased in through 2026), per CMS 2024 Advance Notice:
| ICD-10-CM Code | HCC v28 Category | HCC Number | RAF Impact / Notes |
|---|---|---|---|
| I26.01, I26.02, I26.09 (PE with acute cor pulmonale) | Cor Pulmonale / Right Heart Failure | HCC 223 | Higher RAF weight; acute cor pulmonale documentation is key upgrade from HCC 266 to HCC 223; significant per-member-per-year impact |
| I26.90, I26.92, I26.93, I26.94, I26.99 (PE without acute cor pulmonale) | Vascular Disease | HCC 266 | Lower RAF than HCC 223; still captures PE as an HCC-relevant diagnosis; document annually for MA plan risk adjustment |
| I27.82 (Chronic pulmonary embolism / CTEPH) | Cor Pulmonale / Right Heart Failure | HCC 223 | CTEPH maps to HCC 223 (same as acute cor pulmonale); supports ongoing RAF; requires annual documentation |
| Z86.711 (Personal history of PE) | No HCC mapping | None | History code does not capture RAF — must use active I26.xx or I27.82 for HCC; do not use Z86.711 in place of active PE diagnosis |
| D68.51, D68.59, D68.61, D68.62 (Thrombophilia/APS) | Hematologic Disorders (varies) | See v28 mapping | Coagulation disorders may have HCC impact depending on v28 category; code consistently when documented as active/contributing |
HCC upgrade opportunity: When a Medicare Advantage patient has documented acute PE with echocardiographic evidence of RV dysfunction and the provider has not explicitly documented “acute cor pulmonale,” a compliant CDI query can clarify the diagnosis. The difference in RAF weight between HCC 266 (PE without cor pulmonale) and HCC 223 (PE with cor pulmonale) is clinically significant for Medicare Advantage risk adjustment. Queries must be AHIMA/ACDIS compliant — non-leading, multiple-choice format.
15. CDI Query Templates
All query templates below are formatted per AHIMA/ACDIS 2019 Query Practice Brief standards — non-leading, multiple-choice, with clinically supported context.
| Scenario | Query Wording (Template) |
|---|---|
| PE with echocardiographic RV dilation / McConnell sign, no acute cor pulmonale documented | “Dr. [Name], the echo report for this admission documents RV dilation and McConnell sign in the setting of confirmed pulmonary embolism. Based on your clinical evaluation, does this patient’s presentation represent: (1) Acute cor pulmonale; (2) RV strain/dysfunction without cor pulmonale; (3) Unable to determine; or (4) Other: ___. Please document in the medical record. Clinical documentation supports accurate ICD-10-CM code selection.” |
| PE with fever, bacteremia, suspected septic source | “Dr. [Name], this patient has confirmed pulmonary embolism and bacteremia with [organism] noted on blood cultures. Is the PE related to: (1) Septic pulmonary embolism (infected emboli from [source: tricuspid endocarditis / IV catheter / septic thrombophlebitis / other]); (2) Incidental bacteremia unrelated to PE; (3) Unable to determine; or (4) Other: ___. Documentation of septic PE and its source will support accurate coding.” |
| CTPA showing saddle PE — no explicit saddle documentation in clinical note | “Dr. [Name], the CTPA report for this patient describes a saddle pulmonary embolism at the bifurcation of the main pulmonary artery. Do you agree with this characterization? If so, please document ‘saddle pulmonary embolism’ in your clinical note to support accurate diagnosis coding. Options: (1) Saddle pulmonary embolism confirmed; (2) PE present but not saddle configuration; (3) Unable to determine based on imaging; or (4) Other: ___.” |
| CTPA showing subsegmental-only PE — single vs. multiple | “Dr. [Name], imaging documents pulmonary embolism limited to subsegmental arteries. To ensure coding accuracy using new FY2025 ICD-10-CM codes, can you confirm: (1) Single subsegmental PE; (2) Multiple subsegmental PE; (3) PE extends beyond subsegmental level; or (4) Unable to characterize at this time. Documentation of subsegmental specificity supports accurate coding per FY2025 guidelines.” |
| Concurrent PE and DVT — DVT laterality/site not documented in provider note | “Dr. [Name], the venous duplex report documents [right/left] [femoral/tibial/popliteal] deep vein thrombosis concurrent with the confirmed pulmonary embolism. To assign accurate ICD-10-CM codes, please document the DVT location and laterality in your clinical note. The duplex report describes [details]. Confirm: (1) DVT at [site + laterality] documented; (2) DVT location/laterality uncertain; (3) DVT is chronic/organized only; or (4) Other: ___.” |
| MA patient with chronic PE / CTEPH — HCC documentation needed | “Dr. [Name], this Medicare Advantage patient has a history of pulmonary embolism with evidence of [right heart strain / elevated RVSP / chronic thrombus]. Does this patient have: (1) Chronic thromboembolic pulmonary hypertension (CTEPH) / chronic pulmonary embolism (I27.82); (2) Resolved prior PE with normal pulmonary pressures (Z86.711); (3) Active acute PE superimposed on prior chronic PE; or (4) Unable to determine. Annual documentation of active diagnoses supports accurate risk adjustment.” |
16. Treatments (Clinical)
Clinical treatment of PE is risk-stratified by severity per the 2023 AHA/ACC VTE Scientific Statement and ACP Clinical Guidelines:
Massive PE (High-Risk)
- Systemic thrombolysis (alteplase 100 mg IV over 2 hours) — first-line if no contraindications; reduces RV afterload rapidly; risk of major bleeding ~10%, intracranial hemorrhage ~2%
- Surgical embolectomy (CPT 32141) — for patients who fail or have absolute contraindications to thrombolysis; high-volume centers only
- Extracorporeal membrane oxygenation (ECMO) — bridge to intervention in refractory shock; emerging evidence supports VA-ECMO as rescue therapy
- UFH anticoagulation concurrent with resuscitation; vasopressors for hemodynamic support
Submassive PE (Intermediate-Risk)
- Anticoagulation alone remains standard for most submassive PE per current guidelines
- Catheter-directed thrombolysis (CDT) — low-dose tPA via catheter into pulmonary arteries; reduces RV dilation faster than anticoagulation alone; considered for deteriorating submassive PE per SEATTLE II and PERFECT registry data
- Ultrasound-assisted CDT (EKOS/EkoSonic) — acoustic energy facilitates thrombus penetration; FDA-cleared; covered by many payers for intermediate-risk PE
- PE Response Teams (PERT) — multidisciplinary rapid response teams; endorsed by major cardiovascular societies to standardize submassive PE management
Low-Risk / Subsegmental PE
- Anticoagulation with DOAC (apixaban, rivaroxaban preferred for most patients) for 3–6 months minimum
- For isolated SSPE without proximal DVT: clinical observation without anticoagulation may be appropriate in low-recurrence-risk patients per AHA guidance
- Early discharge protocols (outpatient management using PESI score or Hestia criteria) when hemodynamically stable
Special Populations
- Pregnancy: LMWH throughout pregnancy; warfarin/DOACs contraindicated in first trimester and near delivery; IVC filter if anticoagulation contraindicated
- Cancer-associated PE: LMWH (dalteparin/enoxaparin) or apixaban/rivaroxaban based on bleeding risk and cancer type; longer duration anticoagulation typically required
- HIT (heparin-induced thrombocytopenia): Discontinue all heparin products; transition to fondaparinux, argatroban, or bivalirudin
- IVC filter placement (37191–37193): Reserved for patients with acute PE who have absolute contraindications to anticoagulation; retrievable filters preferred; retrieve when anticoagulation resumes
Secondary Prevention and Long-Term Management
- Duration of anticoagulation: 3 months (provoked, reversible risk factor) vs. extended/indefinite (unprovoked, recurrent, or high-recurrence-risk PE per current VTE guidelines)
- Annual echo follow-up for patients at risk for CTEPH (I27.82)
- Thrombophilia workup (D68.51–D68.62) in patients with unprovoked PE, recurrent events, or family history
17. Patient Education / Summary
The following educational content supports patient-facing documentation, discharge instructions, and coding of patient education encounters:
What Is a Pulmonary Embolism?
A pulmonary embolism (PE) is a blood clot that has traveled to the lungs, blocking one or more blood vessels. Most PE clots start as deep vein thrombosis (DVT) — a clot in the leg or arm veins — and break loose to travel to the lungs. PE can cause serious problems with breathing and can be life-threatening if not treated quickly, according to NHLBI.
Warning Signs to Know
- Sudden shortness of breath, especially at rest
- Sharp chest pain that gets worse with breathing
- Coughing up blood
- Fast heart rate or feeling faint
- Leg swelling, redness, or pain (possible DVT)
- Call 911 immediately if these symptoms occur
Reducing Your Risk
- Move legs frequently on long trips (car, plane); use compression stockings when prescribed
- Take blood-thinning medications exactly as prescribed — do not skip doses
- Stay hydrated; avoid prolonged immobility after surgery or illness
- Tell your doctor if you have a family history of blood clots or a clotting disorder (thrombophilia)
- Avoid smoking, which increases clotting risk per CDC Blood Clot Prevention
Living With / After PE
- Anticoagulation: Most patients require 3 months to indefinite blood-thinning medication. Follow all lab monitoring instructions (INR checks for warfarin; no routine labs needed for DOACs but follow-up appointments are essential).
- Post-PE syndrome: Some patients experience persistent dyspnea, fatigue, and reduced exercise tolerance after PE. Discuss post-PE functional recovery with your physician.
- CTEPH awareness: A small percentage of patients develop chronic thromboembolic pulmonary hypertension (CTEPH) — shortness of breath that doesn’t improve after treatment. This requires specialist evaluation and is treated differently from acute PE.
- Coding implications: Once PE is resolved, document clearly as “resolved” or “history of PE” so future care teams and coders can assign Z86.711 appropriately rather than re-activating the diagnosis.
For CDI Specialists — Documentation Checklist
- ☑ PE location confirmed: saddle / lobar / segmental / subsegmental (single or multiple)
- ☑ Acute cor pulmonale explicitly documented (if present)
- ☑ Concurrent DVT documented with site + laterality + acute/chronic
- ☑ Septic PE: source organism/site documented
- ☑ Obstetric patients: trimester or postpartum status documented
- ☑ Anticoagulant type and duration documented; Z79.01 supported
- ☑ Thrombophilia workup results documented if relevant
- ☑ Resolved PE documented as “resolved” for Z86.711 at follow-up encounters
About this Guide
This Clinical Documentation Guide is published by CCO Academy and is intended for credentialed coding, CDI, and clinical documentation professionals. Content is updated for FY2026 ICD-10-CM (effective October 1, 2025). All code assignments should be verified against the official ICD-10-CM Tabular List, AHA Coding Clinic, and applicable payer-specific policies. This guide does not constitute legal, medical, or compliance advice.
Last reviewed: April 2026 · Next scheduled review: October 2026 (FY2027 update)
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