D61.01
BillableConstitutional (pure) red blood cell aplasia
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is D61.01 an HCC code?
Yes. D61.01 maps to Hemolytic and Aplastic Anemias under the CMS-HCC V28 risk adjustment model (and Severe Hematological Disorders under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for D61.01
For D61.01 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- 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
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed D61.01 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
D61.01 is the ICD-10-CM diagnosis code for constitutional (pure) red blood cell aplasia. A rare inherited condition present from birth where the bone marrow fails to produce red blood cells due to genetic factors. D61.01 sits in the ICD-10-CM chapter for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (d50-d89), within the section covering aplastic and other anemias and other bone marrow failure syndromes (d60-d64).
Under the CMS-HCC V28 risk adjustment model, D61.01 maps to Hemolytic and Aplastic Anemias (HCC 109) with a community, non-dual, aged base RAF weight of 0.291. Under the older CMS-HCC V24 model, D61.01 maps to Severe Hematological Disorders (HCC 46) with a community, non-dual, aged base RAF weight of 0.666. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
This code indicates a congenital/inherited condition; document family history and genetic testing results if available. Because D61.01 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. 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, RAF weights, and MEAT documentation criteria for D61.01 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This code indicates a congenital/inherited condition; document family history and genetic testing results if available
- •Distinguish from acquired forms by confirming the condition's presence from early childhood or infancy
Clinical Significance
Constitutional (pure) red blood cell aplasia, also known as Diamond-Blackfan anemia, is a rare inherited bone marrow failure syndrome characterized by selective failure of red blood cell production presenting in infancy or early childhood. Approximately 25% of patients have associated congenital anomalies including craniofacial defects, upper limb abnormalities (particularly thumb anomalies), cardiac defects, and short stature. The condition is caused by mutations in ribosomal protein genes and carries an increased lifetime risk of myelodysplastic syndrome, acute myeloid leukemia, and solid tumors.
Documentation Requirements
- ✓Document the congenital/inherited nature confirmed by early-childhood onset and genetic testing when available.
- ✓Record hemoglobin levels, reticulocyte count, elevated erythrocyte adenosine deaminase activity (a diagnostic marker), and bone marrow biopsy showing selective erythroid hypoplasia.
- ✓Include any associated congenital anomalies.
- ✓Document treatment approach (corticosteroid therapy, chronic transfusion program, or stem cell transplant considerations) and response.
- ✓Note any family history of the condition.
Excludes 1 — Do NOT code together
- acquired red cell aplasia (D60.9)
Commonly Confused Codes
- •D60.0 (Chronic acquired pure red cell aplasia) is acquired, not constitutional.
- •D61.03 (Fanconi anemia) is a different inherited bone marrow failure syndrome affecting all cell lines.
- •D61.09 (Other constitutional aplastic anemia) is a less specific inherited aplasia code.
- •D61.02 (Shwachman-Diamond syndrome) involves neutropenia and pancreatic insufficiency rather than isolated red cell failure.