D81.5
BillablePurine nucleoside phosphorylase [PNP] deficiency
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is D81.5 an HCC code?
Yes. D81.5 maps to Common Variable and Combined Immunodeficiencies under the CMS-HCC V28 risk adjustment model (and Disorders of Immunity 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 D81.5
For D81.5to 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 D81.5 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
D81.5 is the ICD-10-CM diagnosis code for purine nucleoside phosphorylase [pnp] deficiency. A rare genetic disorder where the body lacks an enzyme called purine nucleoside phosphorylase, leading to a weakened immune system and neurological problems. D81.5 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 certain disorders involving the immune mechanism (d80-d89).
Under the CMS-HCC V28 risk adjustment model, D81.5 maps to Common Variable and Combined Immunodeficiencies (HCC 114) with a community, non-dual, aged base RAF weight of 2.262. Under the older CMS-HCC V24 model, D81.5 maps to Disorders of Immunity (HCC 47) with a community, non-dual, aged base RAF weight of 0.665. 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 is a specific enzyme deficiency within combined immunodeficiency; do not use D81.9 if this specific deficiency is documented. Because D81.5 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 D81.5 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This is a specific enzyme deficiency within combined immunodeficiency; do not use D81.9 if this specific deficiency is documented
- •Often presents with severe infections, developmental delays, and autoimmune manifestations; document associated conditions separately
Clinical Significance
Purine nucleoside phosphorylase deficiency is a rare autosomal recessive immunodeficiency affecting purine metabolism, leading to progressive T-cell depletion due to accumulation of toxic deoxyguanosine triphosphate in lymphocytes. Uniquely, this condition also causes significant neurological manifestations including developmental delay, spasticity, and ataxia in approximately two-thirds of patients, distinguishing it from other combined immunodeficiencies.
Documentation Requirements
- ✓Documentation must include purine nucleoside phosphorylase enzyme activity levels, elevated uric acid levels (characteristically low in this condition despite being a purine disorder), lymphocyte subset analysis showing progressive T-cell decline, neurological assessment findings, and treatment plan.
- ✓Document any autoimmune manifestations and the distinction from adenosine deaminase deficiency.
Commonly Confused Codes
- •D81.31 (severe combined immunodeficiency due to adenosine deaminase deficiency, a different purine metabolism enzyme with different clinical features), D81.30 (adenosine deaminase deficiency, unspecified), D81.2 (severe combined immunodeficiency with low or normal B-cells from non-enzymatic causes), D81.89 (other combined immunodeficiencies without specified enzymatic defect).