diff --git a/tests/v1/core/test_kv_cache_utils.py b/tests/v1/core/test_kv_cache_utils.py
index 8153fed69..d8ecf28cb 100644
--- a/tests/v1/core/test_kv_cache_utils.py
+++ b/tests/v1/core/test_kv_cache_utils.py
@@ -447,12 +447,12 @@ def test_generate_block_hash_extra_keys():
 
     # Test with no extra keys
     extra_keys, next_mm_idx = generate_block_hash_extra_keys(request, 0, 5, 0)
-    assert extra_keys == ("hash1",)
+    assert extra_keys == (("hash1", 0),)
     assert next_mm_idx == 1
 
     # Test with partial overlap
     extra_keys, next_mm_idx = generate_block_hash_extra_keys(request, 3, 8, 0)
-    assert extra_keys == ("hash1",)
+    assert extra_keys == (("hash1", -3),)
     assert next_mm_idx == 1
 
     # Test with no overlap
@@ -462,7 +462,7 @@ def test_generate_block_hash_extra_keys():
 
     # Test with multiple extra keys
     extra_keys, next_mm_idx = generate_block_hash_extra_keys(request, 0, 15, 0)
-    assert extra_keys == ("hash1", "hash2")
+    assert extra_keys == (("hash1", 0), ("hash2", 10))
     assert next_mm_idx == 2
 
 
@@ -513,7 +513,7 @@ def test_generate_block_hash_extra_keys_cache_salt():
 
     # Test with no extra keys
     extra_keys, next_mm_idx = generate_block_hash_extra_keys(request_mm, 0, 5, 0)
-    assert extra_keys == ("hash1", "salt")
+    assert extra_keys == (("hash1", 0), "salt")
     assert next_mm_idx == 1
 
 
@@ -637,8 +637,10 @@ def test_request_block_hasher(hash_fn):
 
     block_hashes = request.block_hashes
     assert len(block_hashes) == 2
-    assert block_hashes[0] == hash_fn((kv_cache_utils.NONE_HASH, (0, 1, 2), ("hash1",)))
-    assert block_hashes[1] == hash_fn((block_hashes[0], (3, 4, 5), ("hash2",)))
+    assert block_hashes[0] == hash_fn(
+        (kv_cache_utils.NONE_HASH, (0, 1, 2), (("hash1", 0),))
+    )
+    assert block_hashes[1] == hash_fn((block_hashes[0], (3, 4, 5), (("hash2", 0),)))
 
 
 @pytest.mark.parametrize("hash_fn", [sha256, sha256_cbor])
@@ -1973,7 +1975,7 @@ def test_request_with_prompt_embeds_and_mm_inputs(hash_fn: Callable[[Any], bytes
         (
             kv_cache_utils.NONE_HASH,
             tuple(prompt_token_ids[:block_size]),
-            ("hash1", block1_embeds_hash),
+            (("hash1", 0), block1_embeds_hash),
         )
     )
     assert block_hashes[0] == expected_hash1
@@ -1985,7 +1987,7 @@ def test_request_with_prompt_embeds_and_mm_inputs(hash_fn: Callable[[Any], bytes
         (
             block_hashes[0],
             tuple(prompt_token_ids[block_size:num_tokens]),
-            ("hash2", block2_embeds_hash),
+            (("hash2", 0), block2_embeds_hash),
         )
     )
     assert block_hashes[1] == expected_hash2
diff --git a/tests/v1/core/test_prefix_caching.py b/tests/v1/core/test_prefix_caching.py
index 28355eb54..b8b387fff 100644
--- a/tests/v1/core/test_prefix_caching.py
+++ b/tests/v1/core/test_prefix_caching.py
@@ -1570,20 +1570,24 @@ def test_mm_prefix_caching():
     block_hashes = req0.block_hashes
     assert len(block_hashes) == 3
     assert block_hashes[0] == sha256(
-        (kv_cache_utils.NONE_HASH, tuple(all_token_ids[:block_size]), ("aaa",))
+        (
+            kv_cache_utils.NONE_HASH,
+            tuple(all_token_ids[:block_size]),
+            (("aaa", 11),),
+        )
     )
     assert block_hashes[1] == sha256(
         (
             block_hashes[0],
             tuple(all_token_ids[block_size : block_size * 2]),
-            ("aaa", "bbb"),
+            (("aaa", -5), ("bbb", 14)),
         )
     )
     assert block_hashes[2] == sha256(
         (
             block_hashes[1],
             tuple(all_token_ids[block_size * 2 : block_size * 3]),
-            ("bbb",),
+            (("bbb", -2),),
         )
     )
 
@@ -1603,7 +1607,11 @@ def test_mm_prefix_caching():
     assert new_blocks is not None and len(new_blocks.blocks[0]) == 0
     assert len(block_hashes) == 4
     assert block_hashes[3] == sha256(
-        (block_hashes[2], tuple(all_token_ids[3 * block_size :] + [8] * 5), ("ccc",))
+        (
+            block_hashes[2],
+            tuple(all_token_ids[3 * block_size :] + [8] * 5),
+            (("ccc", 0),),
+        )
     )
 
     # Cache hit.
diff --git a/vllm/v1/core/kv_cache_utils.py b/vllm/v1/core/kv_cache_utils.py
index 83ada0530..9ab5af0f6 100644
--- a/vllm/v1/core/kv_cache_utils.py
+++ b/vllm/v1/core/kv_cache_utils.py
@@ -413,7 +413,7 @@ def _gen_mm_extra_hash_keys(
     # We do not need to check all mm inputs if the start token index is out of
     # range. This usually happens in the late prefill phase and decoding phase.
     last_pos = mm_features[-1].mm_position
-    if last_pos.offset + last_pos.length < start_token_idx:
+    if last_pos.offset + last_pos.length <= start_token_idx:
         return extra_keys, start_mm_idx
 
     # Support start_mm_idx == -1 to indicate the last mm input.
@@ -428,13 +428,16 @@ def _gen_mm_extra_hash_keys(
         offset = mm_feature.mm_position.offset
         length = mm_feature.mm_position.length
         if end_token_idx > offset:
-            if start_token_idx > offset + length:
+            if start_token_idx >= offset + length:
                 # This block has passed the current mm input.
                 curr_mm_idx += 1
                 continue
 
-            # The block contains the current mm input.
-            extra_keys.append(mm_feature.identifier)
+            # The block contains the current mm input. Include its offset
+            # relative to the start of the block so prefix-cache keys stay
+            # distinct when the same MM item appears at different positions
+            # within otherwise-identical placeholder blocks.
+            extra_keys.append((mm_feature.identifier, offset - start_token_idx))
 
             if end_token_idx >= offset + length:
                 # If this block contains the end of the current mm input,