ICD-10 K63.1
Billable / Specific HCC v28: 33 MCCPerforation of intestine (nontraumatic)
About ICD-10-CM K63.1
ICD-10-CM code K63.1 represents Perforation of intestine (nontraumatic). This is a billable/specific code in the Digestive System chapter (block K63). The 2026 edition of ICD-10-CM K63.1 became effective on October 1, 2025.
Coding Tips for K63.1
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
K63.1 is a CMS-HCC v28 risk-adjustment code (category 33). To count for the patient Risk Adjustment Factor (RAF), document the diagnosis with MEAT language each calendar year: Monitored, Evaluated, Assessed, Treated. A diagnosis on the problem list alone does not satisfy CMS RADV audit standards. Include the diagnosis in the assessment with current status and current treatment plan.
K63.1 is designated MCC for MS-DRG grouping. On inpatient claims, this code can shift the DRG to the with-MCC variant when documented as a present-on-admission secondary diagnosis. Hospital CDI programs flag MCC opportunities during chart review. Failure to capture this code may leave 30 to 80 percent of the inpatient stay revenue unrealized.
Inclusion Terms / Approximate Synonyms
Clinical terms and conditions classified under K63.1. Per CMS ICD-10-CM Tabular 2026.
- Perforation (nontraumatic) of rectum
Type 1 Excludes
Pure excludes, these codes can never be coded together with K63.1. The conditions are mutually exclusive (e.g., congenital vs acquired forms).
- perforation (nontraumatic) of duodenum (K26.-)
- perforation (nontraumatic) of intestine with diverticular disease (K57.0, K57.2, K57.4, K57.8)
Type 2 Excludes
Not included here, the excluded code is not part of K63.1, but a patient may have both conditions at the same time. Both codes may be coded together when applicable.
- perforation (nontraumatic) of appendix (K35.2-, K35.3-)
Medicare Advantage HCC Impact
Capture this diagnosis annually for accurate risk adjustment. Missed HCC captures are the #1 revenue leak in Medicare Advantage risk programs.
Inpatient DRG Impact, MCC
code Perforation of intestine (nontraumatic). As a Major Complication/Comorbidity (MCC), this can shift the DRG assignment to a higher-weighted category, substantial reimbursement impact.
Medicare LCD Coverage for K63.1
Local Coverage Determinations (LCDs) from CMS MACs that list K63.1 as a covered diagnosis.
Showing top 10 of 168 total . Click a CPT for full coverage scope.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing K63.1.
5 Medicare
CPT Codes Commonly Billed with K63.1
Procedures frequently paired with this diagnosis based on PayerReady's Dx↔Px linkage data.
We don't have CPT pairings indexed for this specific code yet. Use the CPT search above to find common procedures, or check your payer's published medical policy for code-specific guidance.
Convert K63.1 to ICD-9-CM
Per CMS General Equivalence Mappings (GEMs), useful for legacy data review and historical claim analysis.
| ICD-10 | ICD-9 | Mapping Flags |
|---|---|---|
| K63.1 | 56983 | 00000 |
Flags format (5 digits): Approximate · No Map · Combination · Scenario · Choice List. Source: CMS 2017 GEMs (final version).
Codes Adjacent To K63.1
Other codes in section K55-K64 (Other diseases of intestines).
ICD-10 K63.1, Billing FAQ
Is ICD-10 code K63.1 billable? +
Yes, K63.1 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
What other names or terms map to K63.1? +
ICD-10 K63.1 includes: Perforation (nontraumatic) of rectum.
What codes are Type 1 Excludes for K63.1? +
Type 1 Excludes (never code together with K63.1): perforation (nontraumatic) of duodenum (K26.-); perforation (nontraumatic) of intestine with diverticular disease (K57.0, K57.2, K57.4, K57.8)
What codes are Type 2 Excludes for K63.1? +
Type 2 Excludes (may be coded together when both conditions exist): perforation (nontraumatic) of appendix (K35.2-, K35.3-)
Does K63.1 affect Medicare Advantage HCC risk adjustment? +
Yes. K63.1 maps to CMS-HCC v28 category 33. Capture this diagnosis annually for accurate Medicare Advantage risk score.
Is K63.1 a CC or MCC for inpatient DRG? +
Yes, this code is designated as MCC. Documenting as a secondary diagnosis on inpatient claims can shift the DRG to a higher-weighted category.
What ICD-9 codes does K63.1 map to? +
Per CMS GEMs, K63.1 maps to ICD-9 codes: 56983. Useful for legacy data review and historical claim analysis.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on July 16, 2026.
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