K92.1

🧬 ICD-10-CM K92.1 — Melena

Billable Code Confirmed

ICD-10 CM K92.1 is a valid, billable 4-character ICD-10-CM code for FY2026. The K92 category defines other diseases of the digestive system, and the 1 character specifies the condition strictly as melena. No additional characters are required.

Non-Billable Parent Codes — Never Submit These

• ❌ K92 — 3-character header — Lacks specificity regarding the type or clinical manifestation of the digestive system hemorrhage.

Always submit K92.1 (all 4 characters) when the passage of black, tarry stools is documented and a definitive underlying cause has not yet been established.

Clinical Context: Symptom vs. Definitive Diagnosis

ICD-10 CM K92.1 captures a clinical sign/symptom. According to ICD-10-CM guidelines, if the underlying etiology of the melena is definitively diagnosed by the provider (e.g., bleeding duodenal ulcer, gastric varices, or bleeding angiodysplasia), the definitive diagnosis must be coded instead of K92.1. K92.1 is used when the cause of the digested blood remains unknown or unverified after clinical evaluation.

Code Classification

ICD-10-CM Diagnosis Code — wRVU, assistant payable, and global period fields are not applicable; direct reader to CPT Procedural Crosswalk and ICD-10-PCS Crosswalk sections.

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🔍 Code Description

ICD-10-CM K92.1 classifies melena. This code represents the passage of abnormally dark, tarry, and foul-smelling feces containing digested blood.

Pathophysiologically, melena indicates that a hemorrhage has occurred in the upper gastrointestinal tract (typically the esophagus, stomach, or duodenum, above the ligament of Treitz). The black color and tarry consistency are the result of hemoglobin being altered by digestive enzymes and intestinal bacteria as it transits through the gut. It represents a medical emergency that requires rapid evaluation, potential volume resuscitation, and urgent esophagogastroduodenoscopy (EGD) to identify the bleeding source.

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🌳 Code Tree / Hierarchy

K90-K95 Other diseases of the digestive system ❌ Non-billable
│
├── K90 Intestinal malabsorption ❌ Non-billable
├── K91 Postprocedural complications and disorders of digestive system, not elsewhere classified ❌ Non-billable
├── K92 Other diseases of digestive system ❌ Non-billable
│ │
│ ├── K92.0 Hematemesis ✅ Billable
│ ├── K92.1 Melena ◀ THIS CODE ✅ Billable
│ └── K92.2 Gastrointestinal hemorrhage, unspecified ✅ Billable
│
└── K94 Complications of artificial openings of the digestive system ❌ Non-billable

Coding Unspecified GI Bleeds

If a provider documents “Upper GI Bleed” without specifically documenting the clinical manifestation of black/tarry stools (melena) or vomiting blood (hematemesis), the default code is K92.2 (Gastrointestinal hemorrhage, unspecified). Query the provider if the clinical picture suggests melena to secure the more specific K92.1 code.

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✅ Includes

The following clinical terms and scenarios map to K92.1 when documented:

• Melena NOS

• Black, tarry stools

• Digested blood in stool/feces

• Upper GI bleed presenting as dark stool

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❌ Excludes

Excludes 1 — Cannot Be Coded Simultaneously with K92.1

Code	Description	Note
K92.2	Gastrointestinal hemorrhage, unspecified	Mutually exclusive. Melena specifies the nature of the hemorrhage. Never code an unspecified hemorrhage code alongside a specific one for the same clinical event.
R19.5	Occult blood in feces	Mutually exclusive. Occult blood is microscopic and invisible to the naked eye (found via Guaiac test). Melena is gross, visibly digested blood.
P54.1	Neonatal melena	Mutually exclusive based on patient age. Use P54.1 strictly for newborns.
K25.0-K28.0	Peptic ulcer with hemorrhage	Mutually exclusive. If the melena is definitively proven to be caused by a bleeding ulcer, code the ulcer. The symptom of melena is inherent to the bleeding ulcer.

Excludes 1 Violation Risk

A frequent error is coding K92.1 alongside an underlying cause like K26.0 (Acute duodenal ulcer with hemorrhage). ICD-10-CM logic dictates that the symptom code (K92.1) must be dropped once the definitive bleeding pathology is established by the provider.

Excludes 2 — May Be Coded in Addition if Separately Present

Code	Description	Note
N/A	There are no Excludes 2 notes specifically restricting K92.1.

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📋 Clinical Overview

Phenotype Distinction: GI Bleed Manifestations

Differentiating the physical presentation of the gastrointestinal bleed dictates whether K92.1, K92.0, or lower GI codes are appropriate.

Feature	K92.1 — Melena	K92.0 — Hematemesis	K62.5 — Hemorrhage of rectum
Typical Source	Upper GI (Esophagus, Stomach, Duodenum)	Upper GI (Esophagus, Stomach)	Lower GI (Left Colon, Rectum, Anus)
Appearance	Black, tarry, foul-smelling stool	Vomiting bright red blood or coffee-grounds	Bright red blood per rectum (Hematochezia)
Clinical Speed	Slower transit, allows for digestion of blood	Brisk, rapid upper transit	Variable, localized to distal tract

CDI Query Trigger — "UGIB"

“Upper GI Bleed” (UGIB) is a vague diagnostic statement that defaults to K92.2 (unspecified). If the nursing flowsheets and H&P describe the patient passing “black tarry stools,” send a clinical validation query asking the provider to formally document “Melena” to capture K92.1.

Manifestations & Symptom Burden

Common systemic manifestations resulting from the blood loss associated with K92.1 include:

• Acute Blood Loss Anemia: Rapid drop in hemoglobin/hematocrit.

• Lethargy and Weakness: Due to decreased oxygen-carrying capacity.

• Hypotension & Tachycardia: Signs of hemodynamic instability/hypovolemia.

Coding Manifestations

Always code the documented systemic effects to fully capture the patient’s severity of illness. Examples include:

• D62 — Acute posthemorrhagic anemia (Often acts as a CC)

• R57.1 — Hypovolemic shock

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💰 HCC Risk Adjustment (CMS-HCC v28)

Field	Detail
CMS-HCC Model Version	v28 (2024-2025 Implementation)
HCC Assignment	✅ Mapped — HCC 151
HCC Category	HCC 151 — Gastrointestinal Hemorrhage
RAF Coefficient	~0.25 - 0.35 (varies by demographic/status)

K92.1 maps directly to an HCC and contributes to the RAF score.

Capture Annually

While melena is typically an episodic acute event, accurately capturing K92.1 is critical during the encounter where the bleeding occurs. It validates the high resource utilization (transfusions, endoscopies) required for the patient’s care. Always prioritize identifying and coding the underlying chronic etiology (e.g., angiodysplasia) for long-term risk adjustment.

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🏥 DRG Assignment

MDC 06 — Diseases and Disorders of the Digestive System

DRG	Title	Est. Relative Weight*
DRG 377	G.I. Hemorrhage with MCC	~1.65
DRG 378	G.I. Hemorrhage with CC	~0.95
DRG 379	G.I. Hemorrhage without CC/MCC	~0.65

Approximate. Verify against IPPS FY2026 Final Rule tables.

Sequencing and Complications

K92.1 is correctly sequenced as the principal diagnosis when a patient is admitted for melena, an EGD is performed, and no definitive bleeding source is found (e.g., the bleeding has stopped and the mucosa is normal). If K92.1 develops during a hospital stay for a different condition, it acts as a Complication or Comorbidity (CC), which will shift the DRG to a higher-weighted tier.

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🔗 Related ICD-10-CM Codes

Phenotype Variants

Code	Description
K92.1	Melena ← This Code
K92.0	Hematemesis
K92.2	Gastrointestinal hemorrhage, unspecified

Definitive Etiology Variants (Code instead of K92.1 if known)

Code	Description
K26.0	Acute duodenal ulcer with hemorrhage
K25.0	Acute gastric ulcer with hemorrhage
K31.811	Angiodysplasia of stomach and duodenum with bleeding

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🛠️ Commonly Associated CPT Codes (Outpatient & Profee)

Outpatient and Profee Setting Context

K92.1 provides robust medical necessity for urgent diagnostic and therapeutic esophagogastroduodenoscopy (EGD) procedures to evaluate the upper GI tract.

CPT Code	Description	Profee Coding Notes (Modifier 26)
43235	EGD, flexible, transoral; diagnostic	Billed if the source is evaluated but no intervention is performed.
43255	EGD, flexible, transoral; with control of bleeding, any method	Billed if hemostasis (clips, cautery, epinephrine) is achieved.
36430	Transfusion, blood or blood components	Billed for professional oversight of blood transfusion if criteria are met.

NCCI Bundling Considerations

• 43235 (Diagnostic EGD) billed on the same day as 43255 (Therapeutic EGD for bleeding). The diagnostic portion is bundled into the therapeutic intervention. Report only 43255.

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🔬 ICD-10-PCS Crosswalk (Inpatient Procedures)

When K92.1 is an inpatient diagnosis, these PCS codes are relevant for associated inpatient evaluations and resuscitations.

PCS Section	Body System	Root Operation	Clinical Application
0 (Medical/Surgical)	D (Gastrointestinal System)	J (Inspection)	Bedside or OR diagnostic EGD to locate the source of melena: 0DJ08ZZ (Inspection of Upper Intestinal Tract, Via Natural or Artificial Opening Endoscopic).
3 (Administration)	0 (Circulatory)	2 (Transfusion)	PRBC transfusion via peripheral IV for acute blood loss: 30233N1 (Transfusion of Nonautologous Red Blood Cells into Peripheral Vein, Percutaneous Approach).

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💊 Coding Scenarios and Examples

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Scenario 1 — ED to Inpatient Admission: Undetermined Source

Clinical Vignette: A 55-year-old male presents to the ED reporting three days of weakness and passing black, foul-smelling stools. His hemoglobin is 7.2 g/dL. He is admitted and transfused 2 units of PRBCs. A GI consult performs an urgent EGD, which reveals mild diffuse erythema in the stomach but no active bleeding, ulcers, or stigmata of recent hemorrhage. The bleeding resolves. The provider’s final diagnosis is “Upper GI bleed presenting as melena, source undetermined.”

Principal Diagnosis:

• K92.1 — Melena (The definitive symptom that prompted admission; a specific etiology could not be found after study).

Secondary Diagnoses:

• D62 — Acute posthemorrhagic anemia (Condition supported by low Hgb, blood transfusion, and clinical context; acts as a CC).

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Scenario 2 — Inpatient Complication: Excludes 1 Application

Clinical Vignette: A 70-year-old male is admitted for a severe COPD exacerbation. On hospital day 3, nursing reports a large, black, tarry bowel movement. His hemoglobin drops by 2 grams. An emergent EGD is performed. The endoscopist identifies a 2 cm bleeding duodenal ulcer, which is successfully treated with bipolar cautery.

Principal Diagnosis:

• J44.1 — Chronic obstructive pulmonary disease with (acute) exacerbation (Reason for admission)

Secondary Diagnoses:

• K26.0 — Acute duodenal ulcer with hemorrhage (Condition developed during stay; acts as a CC. Note: K92.1 is NOT coded because the definitive cause of the bleeding—the ulcer—was found).

MS-DRG Assignment: Groups to DRG 191 (COPD with CC), due to the acute bleeding duodenal ulcer elevating the severity tier.

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Scenario 3 — CDI Query: Vague “UGIB” Documentation

Clinical Vignette: A patient is admitted through the ED with “Acute UGIB.” The H&P notes the patient had “two episodes of very dark, tarry stools at home today.” An EGD is inconclusive. The discharge summary lists the final diagnosis simply as “Upper GI Bleed.”

Action / Outcome:

Coding strictly from “Upper GI Bleed” assigns K92.2 (Gastrointestinal hemorrhage, unspecified). However, the H&P contains explicit clinical evidence of melena. A clinical validation query should be sent to the attending provider to incorporate the specific physical manifestation into the final diagnostic statement to ensure optimal specificity and HCC/DRG mapping.

Query Response: Provider updates the discharge summary to state: “Upper GI Bleed presenting as melena.”

Corrected ICD-10-CM Coding:

• K92.1 — Melena (Accurately captures the specific symptom documented in the clinical course).

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⚠️ Coding Pitfalls and Tips

	Pitfall or Tip
❌	Coding Melena with the Underlying Cause. Do not assign K92.1 if the provider’s final diagnosis definitively identifies the bleeding source (e.g., bleeding gastric ulcer, angiodysplasia). ICD-10-CM guidelines dictate coding only the definitive diagnosis.
❌	Defaulting to K92.2. Avoid using K92.2 (Unspecified GI Hemorrhage) if the medical record clearly describes the patient passing black, tarry stools. Query the provider to formally diagnose “melena” for greater specificity.
✅	Code Systemic Manifestations. Melena frequently results in acute blood loss anemia. Always review the lab values (Hgb/Hct) and transfusion records. If acute posthemorrhagic anemia is documented, add D62 to accurately reflect the patient’s severity of illness and secure a CC.
✅	Look for External Causes. If the melena is documented as an adverse effect of a prescribed medication (like NSAIDs or anticoagulants), assign the appropriate Adverse Effect (Y-code) as a secondary diagnosis.

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📚 Sources

1. CMS/NCHS. ICD-10-CM Official Guidelines for Coding and Reporting, FY2026.

2. American College of Gastroenterology (ACG). Clinical Guidelines: Management of Patients with Ulcer Bleeding.

3. CMS. 2025-2026 Medicare Advantage Risk Adjustment — CMS-HCC Model v28 ICD-10-CM Mappings.

4. CMS. IPPS Final Rule FY2026 — MS-DRG Definitions Manual v43. MDC 06 logic tables.

5. AMA. CPT Professional Edition 2026. Surgery / Digestive System.