D61.09
BillableOther constitutional aplastic anemia
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is D61.09 an HCC code?
Yes. D61.09 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 D61.09
For D61.09 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 D61.09 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
D61.09 is the ICD-10-CM diagnosis code for other constitutional aplastic anemia. This is a rare blood disorder where the bone marrow fails to produce enough blood cells (red blood cells, white blood cells, and platelets) due to an inherited or constitutional condition that is not otherwise specified. Patients with this condition are at risk for infections, bleeding, and severe anemia. D61.09 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, D61.09 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, D61.09 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.
Verify the specific type of constitutional aplastic anemia in the medical record, as code D61.09 is used only when the condition doesn't fit more specific subtypes like Fanconi anemia (D61.09 excludes D61.01). Because D61.09 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 D61.09 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify the specific type of constitutional aplastic anemia in the medical record, as code D61.09 is used only when the condition doesn't fit more specific subtypes like Fanconi anemia (D61.09 excludes D61.01)
- •Document whether the condition is congenital or acquired, and look for any associated conditions or complications that may require additional codes
Clinical Significance
Other constitutional aplastic anemia captures rare inherited bone marrow failure syndromes not classified under Diamond-Blackfan anemia, Shwachman-Diamond syndrome, or Fanconi anemia. This includes conditions such as dyskeratosis congenita (telomere biology disorders), congenital amegakaryocytic thrombocytopenia that progresses to aplasia, and other genetic bone marrow failure syndromes identified through advances in genetic testing. These rare conditions share the features of inherited bone marrow failure with varying patterns of cytopenia and associated clinical manifestations.
Documentation Requirements
- ✓Document the specific constitutional aplastic anemia syndrome by name when identified.
- ✓Include genetic testing results confirming the inherited nature.
- ✓Record complete blood count values, bone marrow biopsy findings, and any characteristic physical features associated with the specific syndrome.
- ✓Document family history of bone marrow failure or related conditions.
- ✓Note treatment approach including supportive care, stem cell transplant considerations, and any malignancy surveillance.