2025 ICD-10-CM code K92.1
(Active) Effective Date: N/A Revision Date: N/A Diseases of the digestive system - Other diseases of the digestive system Diseases of the digestive system (K00-K95) Feed
Melena is the passage of black, tarry stools due to the presence of digested blood in the feces.
Medical necessity for investigation of melena is based on the potential for significant blood loss, which can lead to complications such as anemia, hypotension, and shock.The need for further investigation (e.g., endoscopy) depends on the clinical context, including the severity of symptoms and the patient's overall health status.Patients presenting with significant bleeding or hemodynamic instability require urgent intervention.
The clinical responsibility for diagnosing and managing melena involves a thorough evaluation of the patient, including their history of gastrointestinal symptoms, physical examination, and appropriate laboratory tests like a complete blood count, stool guaiac test, and potentially endoscopy to identify the source of bleeding.
In simple words: Melena means that your poop is black and sticky because of digested blood. This usually shows bleeding in your stomach or upper intestines.
K92.1, Melena, is an ICD-10-CM code that signifies the presence of digested blood in the feces, resulting in dark, tarry stools.This indicates bleeding in the upper gastrointestinal tract, typically from a source proximal to the ileocecal valve. The color change is due to the action of digestive enzymes and oxidation.The diagnosis requires clinical correlation with the patient's history, physical examination findings, and other laboratory tests.It is essential to differentiate melena from other causes of dark stools, such as the ingestion of certain medications or food coloring.
Example 1: A 65-year-old male presents with black, tarry stools and complaints of weakness.His history reveals recent NSAID use.A complete blood count shows anemia, and endoscopy reveals a peptic ulcer., A 40-year-old female with a history of cirrhosis reports black stools and abdominal pain.Laboratory tests show decreased hematocrit, and upper endoscopy reveals esophageal varices as the cause., A 70-year-old male with a history of colon cancer presents with melena and hypotension.Emergency endoscopy reveals brisk bleeding from a colonic lesion.
Detailed patient history including gastrointestinal symptoms (e.g., abdominal pain, nausea, vomiting, changes in bowel habits), medication list, relevant allergies, and any past medical history, particularly conditions that might predispose to upper gastrointestinal bleeding.Physical examination findings including vital signs, abdominal examination, and assessment of hydration status.Complete blood count to assess for anemia. Stool guaiac test to confirm the presence of blood.Endoscopic findings with detailed description of lesions or bleeding sites (if endoscopy performed). Results of any other relevant imaging studies (e.g., CT scan).Documentation of the treatment plan and response to treatment.
** While melena usually suggests upper gastrointestinal bleeding, it’s crucial to consider lower gastrointestinal sources in cases where upper endoscopy is non-diagnostic.The severity of bleeding is not reflected in this code; additional codes may be needed to specify the degree of blood loss or its clinical impact.
- Payment Status: Active
- Specialties:Gastroenterology, Hematology, Internal Medicine, Surgery
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Emergency Room - Hospital, Ambulatory Surgical Center