K28.5 ICD-10-CM Code: Chronic or unspecified gastrojejunal ulcer with perforation
K28.5 maps to CMS-HCC V28 78. A source-labeled RAF reference is available. Confirm the documented diagnosis and applicable coding requirements. MEAT criteria · RAF Calculator · HCC coding software
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FY 2026 Apr update / Diseases of the digestive system (K00-K95) / Diseases of esophagus, stomach and duodenum (K20-K31)
K28.5
Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidanceChronic or unspecified gastrojejunal ulcer with perforation
A long-term or unspecified gastrojejunal ulcer with a hole or rupture in the wall.
Buddy Insight
Chronic or unspecified gastrojejunal ulcer with perforation indicates a long-standing or poorly characterized marginal ulcer at a gastrojejunal anastomosis that has perforated.
CMS-HCC V28
MappedHCC 78
Coefficient HCC 78: 0.326 (Community Non-Dual Aged (CNA))
CMS-HCC V24
HistoricalHistorical
Not used for CY2026 payment
ACA/HHS
MappedHCC 042
Code-level coefficient reference
ESRD/PACE
MappedHCC 33
Code-level coefficient reference
RXHCC
N/A—
Not mapped
Code Book Path
Inclusion Terms
OfficialNo inclusion terms are included in this display for K28.5. Check the code and parent instructions in the Code Book.
Excludes 2
Official- certain conditions originating in the perinatal period (P04-P96)Inherited from K00-K95, K20-K31
- certain infectious and parasitic diseases (A00-B99)Inherited from K00-K95, K20-K31
- complications of pregnancy, childbirth and the puerperium (O00-O9A)Inherited from K00-K95, K20-K31
- congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)Inherited from K00-K95, K20-K31
- endocrine, nutritional and metabolic diseases (E00-E88)Inherited from K00-K95, K20-K31
- injury, poisoning and certain other consequences of external causes (S00-T88)Inherited from K00-K95, K20-K31
- neoplasms (C00-D49)Inherited from K00-K95, K20-K31
- symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)Inherited from K00-K95, K20-K31
- hiatus hernia (K44.-)Inherited from K00-K95, K20-K31
Related Codes
Includes
Official- anastomotic ulcer (peptic) or erosionInherited from K28
- gastrocolic ulcer (peptic) or erosionInherited from K28
- gastrointestinal ulcer (peptic) or erosionInherited from K28
- gastrojejunal ulcer (peptic) or erosionInherited from K28
- jejunal ulcer (peptic) or erosionInherited from K28
- marginal ulcer (peptic) or erosionInherited from K28
- stomal ulcer (peptic) or erosionInherited from K28
Excludes 1
Official- primary ulcer of small intestine (K63.3)Inherited from K28
Code First
OfficialNo Code First sequencing instructions are included in this display for K28.5. Check the code and parent instructions in the Code Book.
Use Additional
Official- code to identify:Inherited from K28
- alcohol abuse and dependence (F10.-)Inherited from K28
Code Also
OfficialNo Code Also instructions are included in this display for K28.5. Check the code and parent instructions in the Code Book.
Buddy Documentation Tip
MEAT Support
Audit Caution
Common Mistakes
Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →
Is K28.5 an HCC code?
Yes. K28.5 (Chronic or unspecified gastrojejunal ulcer with perforation) maps to HCC 78, Intestinal Obstruction/Perforation under the CMS-HCC V28 risk adjustment model, with a source-labeled community non-dual aged reference coefficient of 0.326. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes. It is billable for payment year 2026.
Coder answer: K28.5 is billable and maps to V28 HCC 78, Intestinal Obstruction/Perforation. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.
- Code
- K28.5
- Description
- Chronic or unspecified gastrojejunal ulcer with perforation
- HCC (V28)
- HCC 78 — Intestinal Obstruction/Perforation
- RAF reference coefficient
- 0.326
- Billable
- Yes
- Payment year
- 2026
HCC Category Mapping
These are source-labeled model coefficients, not member totals. A category may still be removed by hierarchy or model cleanup rules. Weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member context, hierarchy and cleanup rules, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains available for historical review.
Work K28.5 in the Code Book — tabular path, V28 RAF reference, and MEAT checklist →
MEAT review for K28.5
For K28.5, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule.
- 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
Coder workflow notes
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What This Code Means
K28.5 is the ICD-10-CM diagnosis code for chronic or unspecified gastrojejunal ulcer with perforation. A long-term or unspecified gastrojejunal ulcer with a hole or rupture in the wall. K28.5 sits in the ICD-10-CM chapter for diseases of the digestive system (k00-k95), within the section covering diseases of esophagus, stomach and duodenum (k20-k31).
Under the CMS-HCC V28 risk adjustment model, K28.5 maps to Intestinal Obstruction/Perforation (HCC 78) with a source-labeled community, non-dual, aged reference coefficient of 0.326. For CY2026 non-PACE Medicare Advantage, CMS uses 100% of the 2024 CMS-HCC model (V28). PACE uses a separate model blend. Source-labeled code-level coefficients are references, not member totals. Actual contribution depends on complete member context, hierarchy and cleanup rules, interactions, and model year. HCC Buddy's RAF Calculator supports CMS-HCC V28 PY2026 and shows no score unless every required source and calculation check passes.
Perforation in chronic gastrojejunal ulcer may present with less acute symptoms than acute perforation. For K28.5, confirm that the documentation supports the diagnosis and meets the applicable coding, encounter, program and payer requirements. MEAT (Monitor, Evaluate, Assess, or Treat) is a review mnemonic, not a universal CMS coding rule. 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, source-labeled coefficient references, and MEAT documentation criteria for K28.5 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Perforation in chronic gastrojejunal ulcer may present with less acute symptoms than acute perforation
- •Ensure perforation is confirmed; if hemorrhage is also present, use K28.6 instead
Clinical Significance
Chronic or unspecified gastrojejunal ulcer with perforation indicates a long-standing or poorly characterized marginal ulcer at a gastrojejunal anastomosis that has perforated. Chronic marginal ulcers may reflect ongoing acid exposure at the anastomotic site or ischemia. This complication in a patient with prior gastric surgery requires both acute surgical management and long-term follow-up.
Documentation Requirements
- ✓Provider documentation of chronic or unspecified gastrojejunal ulcer with perforation
- ✓Surgical history confirming gastrojejunal anastomosis
- ✓Evidence of perforation (imaging, operative findings)
- ✓History supporting chronic ulcer disease at the anastomotic site
- ✓Treatment plan including surgical repair and measures to prevent recurrence
Commonly Confused Codes
- •K28.1: Acute gastrojejunal ulcer with perforation: use when acuity is clearly acute
- •K28.6: Chronic or unspecified gastrojejunal ulcer with both hemorrhage and perforation: when bleeding is also present
- •K28.7: Chronic gastrojejunal ulcer without hemorrhage or perforation: no perforation present
- •K25.5: Chronic or unspecified gastric ulcer with perforation: native stomach, not anastomotic site