D61.03
BillableFanconi anemia
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is D61.03 an HCC code?
Yes. D61.03 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 D61.03
For D61.03 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 D61.03 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
D61.03 is the ICD-10-CM diagnosis code for fanconi anemia. Fanconi anemia is a rare inherited blood disorder that affects the bone marrow's ability to produce blood cells, leading to low counts of red blood cells, white blood cells, and platelets. Patients with this condition have an increased risk of developing certain cancers and may experience fatigue, infections, and bleeding problems. D61.03 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, D61.03 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, D61.03 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.
Fanconi anemia is a genetic disorder; verify documentation specifies the type or subtype if available, as there are multiple complementation groups (A through Q). Because D61.03 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 D61.03 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Fanconi anemia is a genetic disorder; verify documentation specifies the type or subtype if available, as there are multiple complementation groups (A through Q)
- •When coding Fanconi anemia, look for associated complications such as cytopenias, infections, or malignancies that should be coded separately to capture the full clinical picture
Clinical Significance
Fanconi anemia is a rare autosomal recessive (or rarely X-linked) inherited bone marrow failure syndrome caused by mutations in DNA repair pathway genes, characterized by progressive pancytopenia, congenital anomalies, and a markedly elevated risk of malignancies. Physical findings may include short stature, cafe-au-lait spots, thumb and radial ray abnormalities, renal malformations, and microcephaly, though up to 30% of patients have no visible anomalies. The median age of bone marrow failure onset is 7 years, with lifetime risks of approximately 50% for acute myeloid leukemia and 25% for head and neck squamous cell carcinomas.
Documentation Requirements
- ✓Document chromosomal breakage analysis (mitomycin C or diepoxybutane testing) confirming Fanconi anemia diagnosis.
- ✓Record the specific complementation group (FANCA through FANCQ) when genetic testing has been performed.
- ✓Include complete blood count trends showing progressive cytopenias, bone marrow biopsy findings, and any congenital anomalies documented on physical examination or imaging.
- ✓Document treatment including androgen therapy, hematopoietic growth factors, transfusion history, and stem cell transplant status.
- ✓Note any malignancy surveillance performed.
Excludes 1 — Do NOT code together
- Fanconi syndrome (E72.0-)
Commonly Confused Codes
- •D61.01 (Constitutional pure red blood cell aplasia) affects only red cells, not all lineages.
- •D61.02 (Shwachman-Diamond syndrome) involves pancreatic insufficiency without DNA repair defects.
- •D61.09 (Other constitutional aplastic anemia) is less specific and should not be used when Fanconi anemia is confirmed.
- •D46.x (Myelodysplastic syndromes) may develop as a complication but is a separate diagnosis requiring additional coding.