Proposed Rule2021-28314
Schedule for Rating Disabilities: The Digestive System
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Published
January 11, 2022
Issuing agencies
Veterans Affairs Department
Abstract
The Department of Veterans Affairs (VA) proposes to amend the Schedule for Rating Disabilities (VASRD or rating schedule) that addresses the Digestive System. These changes add medical conditions not currently in the rating schedule, revise the rating criteria to reflect medical advances that have occurred since the last revision, clarify existing rating criteria, and update medical terminology. The proposed rule also reflects recommendations from the 2007 report of the National Academy of Sciences, Institute of Medicine, "A 21st Century System for Evaluating Veterans for Disability Benefits." In fashioning this proposed rule, VA considered the most up-to-date medical knowledge and clinical practice of gastroenterology and hepatology specialties.
Full Text
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[Federal Register Volume 87, Number 7 (Tuesday, January 11, 2022)]
[Proposed Rules]
[Pages 1522-1551]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2021-28314]
[[Page 1521]]
Vol. 87
Tuesday,
No. 7
January 11, 2022
Part III
Department of Veterans Affairs
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38 CFR Part 4
Schedule for Rating Disabilities: The Digestive System; Proposed Rule
Federal Register / Vol. 87 , No. 7 / Tuesday, January 11, 2022 /
Proposed Rules
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AQ90
Schedule for Rating Disabilities: The Digestive System
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the
Schedule for Rating Disabilities (VASRD or rating schedule) that
addresses the Digestive System. These changes add medical conditions
not currently in the rating schedule, revise the rating criteria to
reflect medical advances that have occurred since the last revision,
clarify existing rating criteria, and update medical terminology. The
proposed rule also reflects recommendations from the 2007 report of the
National Academy of Sciences, Institute of Medicine, ``A 21st Century
System for Evaluating Veterans for Disability Benefits.'' In fashioning
this proposed rule, VA considered the most up-to-date medical knowledge
and clinical practice of gastroenterology and hepatology specialties.
DATES: VA must receive comments on or before March 14, 2022.
ADDRESSES: Comments may be submitted through <a href="http://www.regulations.gov">www.regulations.gov</a> or
mailed to, Compensation Service, 21C, 1800 G Street NW, Suite 644A,
Washington, DC 20006. Comments should indicate that they are submitted
in response to RIN 2900-AQ90--Schedule for Rating Disabilities: The
Digestive System. Comments received will be available at
<a href="http://regulations.gov">regulations.gov</a> for public viewing, inspection or copies.
FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, M.D., M.B.A.,
Medical Officer, Regulations Staff, (210A), Compensation Service,
Veterans Benefits Administration, Department of Veterans Affairs, 810
Vermont Avenue NW, Washington, DC 20420, <a href="/cdn-cgi/l/email-protection#b2808383e2dddedbd1cbe1c6d3d4d49ce4d0d3c4d3d1ddf2c4d39cd5ddc4"><span class="__cf_email__" data-cfemail="0b393a3a5b6467626872587f6a6d6d255d696a7d6a68644b7d6a256c647d">[email protected]</span></a>,
(202) 461-9700. (This is not a toll-free telephone number.)
SUPPLEMENTARY INFORMATION: Since the last update to the rating schedule
section on digestive disorders, important advances in the science and
medical care have occurred in the fields of nutrition,
gastroenterology, and hepatology. Aware of the impact of these changes,
the Veterans Benefits Administration (VBA) collaborated with the
Veterans Health Administration (VHA) to update the VASRD. The VHA
Office of Specialty Care provided VBA with access to leading
authorities in their respective fields to help in this update.
VA proposes to revise 38 CFR 4.110-4.114 pertaining to the
digestive system based on the most up-to-date understanding of
gastrointestinal disorders and associated functional impairment. The
Rome Foundation, a non-profit organization assisting in the diagnosis
and treatment of functional gastrointestinal disorders, has introduced
a system and classification of the various forms of gastrointestinal
dysfunction, known as ``Rome IV.'' See Brian Lacy, ``Bowel Disorders,''
Gastroenterology, 150: 1393-1407 (2016).
In the context of the VASRD, VA has incorporated the concepts and
diagnostic criteria outlined by Rome IV in several DCs covering
functional digestive disorders, including the revised DC 7319
(Irritable Bowel Syndrome) and new DC 7356 (Gastrointestinal
Dysmotility), as discussed below. VA proposes to use these criteria to
rate certain other functional gastrointestinal conditions. VA discusses
the specific amendments proposed in detail below.
Proposed Deletion of 38 CFR 4.110
Section 4.110 advises rating personnel to consider ulcer location
(e.g., gastric, duodenal, marginal) when providing graduated
descriptions and evaluations of peptic ulcers. VA proposes to eliminate
this instruction as obsolete, along with current DCs 7304, 7305, and
7306, all of which also classify ulcers by location. Modern medicine
understands that most peptic ulcers are not due to location but either
to infection (Helicobacter pylori), or the use of medications, such as
aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs). See E.
Lew, ``Chapter 15: Peptic Ulcer Disease,'' in ``Current Diagnosis &
Treatment: Gastroenterology, Hepatology, & Endoscopy'' (N.J.
Greenberger, et al. eds., 2nd ed. 2012). <a href="https://accessmedicine.mhmedical.com/content.aspx?sectionid=105183277&bookid=1621&Resultclick=2">https://accessmedicine.mhmedical.com/content.aspx?sectionid=105183277&bookid=1621&Resultclick=2</a>. Thus, VA
proposes to delete Sec. 4.110.
Proposed Deletion of 38 CFR 4.111
The current Sec. 4.111 discusses a subset of post-gastrectomy
syndromes known as dumping syndrome. However, this section does not
accurately reflect this specific clinical condition, nor does it offer
specific guidance on rating it. Post-gastrectomy syndromes result from
altered form and function of the stomach, which disrupts the stomach's
reservoir capacity, mechanical digestion, and gastric emptying. Post-
gastrectomy syndromes result in persistent gastrointestinal symptoms
such as epigastric pain, nausea, vomiting, early satiety, bloating,
diarrhea, or weight loss. Davis J.L., Ripley R.T., Postgastrectomy
Syndromes and Nutritional Considerations Following Gastric Surgery,
Surg Clin North Am. 2017 Apr;97(2):277-293. (last visited Oct 6, 2021)
<a href="https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0039610916521951?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0039610916521951%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F28325187">https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0039610916521951?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0039610916521951%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F28325187</a>.
As discussed in more detail below, VA proposes to rate dumping
syndrome under new DC 7303, titled ``Chronic complications of upper
gastrointestinal surgery,'' which includes operations, including
bariatric surgery, performed on the esophagus, stomach, pancreas, and
small intestine. Therefore, the material in Sec. 4.111 is unnecessary
and, accordingly, VA proposes to remove it.
Proposed Revisions to 38 CFR 4.112
When first published in 1964, Sec. 4.112 discussed issues related
to significant weight loss in general terms, referred to as
``appreciable weight loss.'' As part of a 2001 VASRD update, VA
introduced and defined the terms ``substantial weight loss'' and
``baseline weight,'' as well as ``minor weight loss'' and ``inability
to gain weight.'' 66 FR 29486 (May 31, 2001). VA incorporated these
definitions in the VASRD to promote greater uniformity in decision
making. Nevertheless, the weight loss requirements among conditions
continue to vary. For instance, duodenal ulcer (DC 7305) currently
requires weight loss productive of impairment of health, while
ulcerative colitis (DC 7323) requires malnutrition.
[[Page 1523]]
In accordance with advancements in medicine and the current state
of food and nutrition science, VA proposes to update the terms
appearing in Sec. 4.112. See Jane V. White et al., ``Consensus
Statement of the Academy of Nutrition and Dietetics/American Society of
Parenteral and Enteral Nutrition Regarding Adult Malnutrition
(Undernutrition),'' 112 J. of Academy of Nutritional Dietetics 730-38
(2012). These changes would include modifications to the current
definitions of ``substantial weight loss,'' ``minor weight loss,''
``inability to gain weight,'' and ``baseline weight,'' and would
provide alternative methods for obtaining a veteran's baseline weight
when this information was not available in the records. All of these
proposed changes are discussed in greater detail below.
Currently, 38 CFR 4.112 defines ``baseline weight'' as the average
weight for the two-year period preceding the onset of the disease.
Weight loss associated with digestive disease prior to military
discharge is generally readily ascertainable from an individual's
service medical records. However, weight loss associated with digestive
disease after military discharge is often less clear, as weight in the
military is not always available to physicians afterwards or the onset
date of the disease is unknown. As such, VA proposes to redefine
``baseline weight'' (also known as ``usual body weight'') as either
documented weight upon discharge from the armed service, if relevant,
or the documented average weight for the two-year period preceding the
onset of illness. If none of this information is available or is no
longer relevant or applicable, VA proposes to estimate the ``baseline
weight'' using the Hamwi formula for ideal body weight (IBW) or the
Body Mass Index (BMI) table. VA acknowledges that the IBW might provide
different results than the BMI tables, depending on the person's body
frame and size. Bhumika Shah et al., ``Comparison of Ideal Body Weight
Equations and Published Height-Weight Tables With Body Mass Index
Tables for Healthy Adults in the United States,'' 21(3) Nutr. Clin.
Pract. 312-19 (2006). VA therefore proposes using either method to
provide the veteran with the most favorable or advantageous baseline
weight under the situations above.
In addition to updating the definition of ``baseline weight,'' VA
proposes to clarify the existing requirements regarding degrees of
weight loss by including the term ``involuntary'' in reference to the
``weight loss,'' as well as indicating that the weight loss must alter
other aspects of health. Moreover, using weight loss to evaluate
digestive disorders assumes that it results in some degree of
functional impairment. VA proposes to clarify this fact, as it is not
clear from the current requirements.
VA also proposes to add the term ``undernutrition'' to Sec. 4.112
to complete a comprehensive definition of weight loss severity.
Nutritionists prefer the term ``undernutrition'' over ``malnutrition''
as the latter is more imprecise, denoting either over- or under-
nutrition. VA intends to define ``undernutrition'' as a deficiency
resulting from involuntary insufficient intake of one or more essential
nutrients, or the inability of the body to absorb, utilize, or retain
such nutrients. This deficiency results in the failure of the body to
maintain normal organ functions and healthy tissues. Jane V. White et
al., ``Consensus Statement of the Academy of Nutrition and Dietetics/
American Society of Parenteral and Enteral Nutrition Regarding Adult
Malnutrition (Undernutrition),'' 112 J. of Academy of Nutritional
Dietetics 730-38 (2012). Signs and symptoms of undernutrition may
include edema, loss of subcutaneous tissue, peripheral neuropathy,
muscle wasting, weakness, abdominal distention, ascites, and BMI below
normal range. Id.
Studies indicate that poor nutritional status, to include severe
undernutrition, can lead to severe impairment of function. See F.
Romagnoni et al., ``Malnutrition disability evaluation,'' 199 Aging
(Milano) 194-99 (June 2011). Severe protein undernutrition can impair
multiple organ systems. Id. Meanwhile, gastrointestinal cancer can lead
to severe malabsorption, gastrointestinal obstruction, bleeding,
chronic diarrhea, and intractable vomiting. Id. Maureen B. Huhmann and
David A. August, ``Nutrition in Gastrointestinal Cancer,'' in
``Nutrition and Gastrointestinal Disease,'' 158-68 (Mark DeLegge ed.
2008), <a href="https://link.springer.com/content/pdf/10.1007%2F978-1-59745-320-2.pdf">https://link.springer.com/content/pdf/10.1007%2F978-1-59745-320-2.pdf</a>. Physicians confirm undernutrition by measuring weight, BMI, and
laboratory results, including serum albumin, transferrin, total
lymphocyte count, and delayed hypersensitivity index. Id. General
treatment consists of correcting fluid and electrolyte imbalances, as
well as nutritional replenishment. Id.
As certain digestive conditions can lead to severe undernutrition
and disability requiring nutritional support, VA proposes rating
criteria that provide for higher levels of disability based, among
other factors, on the type of nutritional support needed. As discussed
in more detail below, VA intends to provide higher ratings for
individuals whose digestive conditions may require total parenteral
nutrition (TPN) or assisted enteral nutrition. VA proposes to define
these terms to assist rating personnel in their application. In brief,
TPN involves a special liquid nutritional mixture given into the blood
through an intravenous catheter. See ``What Is Parenteral Nutrition?''
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
(2012), <a href="http://www.nutritioncare.org/About_Clinical_Nutrition/What_Is_Parenteral_Nutrition/">http://www.nutritioncare.org/About_Clinical_Nutrition/What_Is_Parenteral_Nutrition/</a> (last accessed Aug. 29, 2019). Assisted
enteral nutrition, on the other hand, involves a special liquid food
mixture given through a tube, catheter, or a surgically made hole into
the stomach or small bowel. Id. at <a href="http://www.nutritioncare.org/About_Clinical_Nutrition/What_Is_Enteral_Nutrition/">http://www.nutritioncare.org/About_Clinical_Nutrition/What_Is_Enteral_Nutrition/</a> (last accessed Aug.
29, 2019).
Finally, to more accurately describe Sec. 4.112, VA proposes to
retitle it as ``Weight loss and nutrition.'' VA intends to reorganize
this section into four paragraphs. Paragraph (a) would discuss and
define ``substantial weight loss'' and ``minor weight loss;'' paragraph
(b) would define ``baseline weight;'' paragraph (c) would define
``undernutrition;'' and paragraph (d) would explain TPN and assisted
enteral nutrition.
Proposed Revisions to 38 CFR 4.114
Multiple Ratings Under 38 CFR 4.114
Currently, Sec. 4.114 states that ``[r]atings under diagnostic
codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive
will not be combined with each other. A single evaluation will be
assigned under the diagnostic code which reflects the predominant
disability picture, with elevation to the next higher evaluation where
the severity of the overall disability warrants such elevation.''
As discussed below, VA proposes to add a number of new codes to the
digestive system, including gastroesophageal reflux disease (DC 7206),
Barrett's esophagus (DC 7207), chronic complications of upper
gastrointestinal surgery (DC 7303), liver abscess (DC 7350), pancreas
transplant (DC 7352), celiac disease (DC 7355), gastrointestinal
dysmotility syndrome (DC 7356), and post pancreatectomy syndrome (DC
7357). VA personnel currently rate these conditions analogous to DCs
that VA excludes from combining. VA may combine the new DCs 7206 and
7207, like other esophageal conditions, with other digestive
conditions. However, VA proposes to preclude rating personnel
[[Page 1524]]
from combining the remaining new codes.
Diagnostic Codes 7200 Through 7202
DC 7200 is currently titled, ``Mouth, injuries of.'' VA proposes to
rename it to clarify that it applies to soft tissue injuries that do
not include the tongue or lips. Current criteria remain unchanged.
DC 7201 pertains to injuries of the lips; current criteria direct
rating personnel to evaluate as disfigurement of the face. VA proposes
to specify that it may be rated as either disfigurement of the face
(under DC 7800) or as a painful scar (under DC 7804). This is intented
to provide greater specificity for raters, and permit a potentially
more advantageous rating to claimants based on the facts found by the
rater.
DC 7202 is currently titled ``Tongue, loss of whole or part.'' This
disability usually occurs in association with treatment for
oropharyngeal cancers. The current criteria are based on the amount of
tongue removed and degree of speech impairment. However, the criteria
pose limitations that prevent the accurate assessment of the disability
in this part of the digestive system. First, only the amount of
residual tongue and speech impairment are considered. The most salient
digestive function, swallowing, is completely excluded. Additionally,
the criteria do not account for advances in both medical treatment and
rehabilitation that can restore some (if not all) of any swallowing or
speech function. See D. Lin, M.D., et al. ``Long-term Functional
Outcomes of Total Glossectomy With or Without Total Laryngectomy.''
JAMA Otolaryngol Head Neck Surg, vol 14(9): Pgs 797-803. 2015, <a href="https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2429579">https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2429579</a> (last
visited Oct. 06, 2021).
The proposed revisions are intended to use criteria specifically
focused upon disabilities arising from this part of the digestive
system. The criteria would be revised to address swallowing from an
anatomic perspective, so the criteria elements must reflect this
reality. The 30-percent evaluation level would involve intact oral
nutritional intake with permanently impaired swallowing function
without prescribed dietary modification (for example, impaired
swallowing can present as increased swallowing time or frequent
aspiration). The 60-percent evaluation level involves intact oral
nutritional intake with permanently impaired swallowing function that
requires prescribed dietary modification. The 100-percent evaluation
level involves absent oral nutritional intake. VA proposes two notes to
accompany this diagnostic code. The first note would direct rating
personnel to consider the possibility of awarding special monthly
compensation under 38 CFR 3.350. The second note would indicate only a
medical provider can prescribe dietary modifications for the purposes
of this diagnostic code.
Esophageal Conditions
The proposed changes to esophageal conditions described under
proposed DCs 7203 through 7207 reflect the advances in treatment and
improved understanding of esophageal disease. The proposed DCs contain
more detailed rating criteria involving structural and motility
disorders of the esophagus.
Several validated studies incorporate swallowing dysfunction (due
to stricture) as one of the major manifestations of severity in
esophageal disorders. M. Dakkak and J.R. Bennett, ``A New Dysphagia
Score With Objective Validation,'' 14(2) J. of Clinical
Gastroenterology 99-100 (1992). Thus, the proposed classification and
ratings account for this dysfunction, while also taking into account
changes in weight, the requirement for nutritional support,
complications, and other interventional needs. The proposed higher
rating levels are not exclusively based on esophageal stricture-
dilatation, but offer alternative descriptors for a more comprehensive
evaluation than the current VASRD.
Diagnostic Code 7203
VA proposes to revise the rating criteria for esophageal disorders
that manifest as stricture, currently evaluated under DC 7203. Although
these conditions have a wide spectrum of causation, the manifestations
are similar. As noted above, several validated studies incorporate
swallowing dysfunction (due to stricture) as one of the major
manifestations of severity in esophageal disorders. Dakkak, supra at
99. Thus, the proposed classification and rating reflects this feature.
VA proposes to add Note (3) that provides a non-exhaustive list of the
numerous conditions to which DC 7203 applies. These conditions include
but are not limited to esophagitis, mechanical or chemical; Mallory
Weiss syndrome (bleeding due to tears at the junction of esophagus and
stomach) due to caustic ingestion of alkali or acid; drug-induced or
infectious esophagitis due to Candida, virus, or other organism;
idiopathic eosinophilic or lymphocytic esophagitis; esophagitis,
radiation-therapy induced; esophagitis due to peptic stricture; and any
esophageal condition that requires treatment with sclerotherapy. See
Norton J. Greenberger et al., ``Section 2: Esophageal Diseases'' in
``Current Diagnosis & Treatment: Gastroenterology, Hepatology, &
Endoscopy'' (N.J. Greenberger, et al. eds., 2d ed. 2012).
The current criteria focus on the most common symptom, dysphagia
(difficulty with swallowing). In its most disabling form, dysphagia can
lead to nutritional deficiencies as well as malnutrition in general
(either of which can result in loss of earnings capacity). One of the
shortcomings with the current criteria is with the subjective nature of
terminology such as ``moderate'' and ``severe.'' No concrete, objective
definitions exist for these terms as they pertain to dysphagia.
VA proposes to revise the evaluation criteria using the manner and
intensity of treatment intervention as the underlying framework.
Additionally, VA would take into consideration that the vast majority
of esophageal strictures result from peptic disease. See D. J.
Patterson, et al. ``Natural History of Benign Esophageal Stricture
Treated By Dilatation,'' Gastroenterology, vol 85, pg 347. 1983,
<a href="https://www.gastrojournal.org/article/0016-5085">https://www.gastrojournal.org/article/0016-5085</a>(83)90322-0/pdf (last
visited Oct. 06, 2021). While some strictures are managed over a
relatively short period of time (i.e., within 24 months), other cases
require a long, protracted intervention period. When this occurs, VA
would categorize these cases as either recurrent (defined as the
inability to maintain target esophageal diameter beyond 4 weeks after
the target diameter has been achieved) and refractory (defined as the
inability to achieve target esophageal diameter despite receiving no
fewer than 5 dilation sessions performed at 2-week intervals). See M.
Kochman, et al. ``The refractory and recurrent esophageal stricture: A
definition (letter to the editor),'' Gastrointestinal Endoscopy, vol
62(3) pgs 474-475, 2005, <a href="https://www.giejournal.org/article/S0016-5107">https://www.giejournal.org/article/S0016-5107</a>(05)01917-6/pdf (last visited Oct. 06, 2021). Once a case
progresses to refractory benign esophageal stricture, only 1 in 3 cases
ever achieve clinical resolution (defined as maintenance of dysphagia-
free status for at least 6 months without the need for further
intervention at the end of follow-up). See A. Repici, et al. ``Natural
history and management of refractory benign esophageal strictures,''
Gastrointestinal Endoscopy, vol 84(2), pgs 222-228 (223). 2016. When
longer and more intensive intervention occurs, more provider encounters
are required, leading to a greater loss in earning capacity.
[[Page 1525]]
VA proposes a 0-percent evaluation level for a documented history
of esophageal stricture(s) without daily symptoms or the requirement
for daily medications. VA proposes a 10-percent evaluation for a
documented history of esophageal stricture(s) that requires daily
medications to control dysphagia that is otherwise asymptomatic. VA
proposes a 30-percent evaluation for a documented history of recurrent
or refractory esophageal stricture(s) causing dysphagia which requires
dilatation no more than 2 times per year. VA proposes a 50-percent
evaluation level for a documented history of recurrent or refractory
esophageal stricture(s) causing dysphagia which requires at least one
of the following: (1) Dilation 3 or more times per year, (2) dilation
using steroids at least one time per year, or (3) esophageal stent
placement. VA proposes an 80-percent evaluation for a documented
history of recurrent or refractory esophageal stricture(s) causing
dysphagia where at least one of the following symptoms is present: (1)
Aspiration, (2) undernutrition, and/or (3) substantial weight loss as
defined by Sec. 4.112(a) and where such dysphagia was treated with
either surgical correction or percutaneous esophago-gastrointestinal
tube (PEG tube).
VA also proposes to list 5 notes with DC 7203. The first note would
require medical findings to be documented by barium swallow,
computerized tomography, or esophagogastroduodenoscopy. The second note
would require non-gastrointestinal complications of procedures to be
rated under the appropriate system. The third note would provide a non-
exhaustive list of esophageal conditions to be evaluated under this DC.
Note 4 and Note 5 would define recurrent and refractory strictures,
respectively.
Diagnostic Code 7204
VA proposes to retitle this DC from ``esophagus, spasm of
(cardiospasm)'' to ``esophageal motility disorder.'' The title change
would capture several motor disorders of the esophagus--in addition to
esophageal spasm--to which VA would apply DC 7204. These disorders
include but are not limited to achalasia (cardiospasm), corkscrew and
nutcracker esophagus, esophageal rings including Schatzki rings,
mucosal webs or folds, and other conditions influencing motility, such
as myasthenia gravis, scleroderma, and other neurological conditions.
VA would not substantively change the existing instruction to rate
conditions falling under this DC as esophageal stricture (DC 7203).
However, VA proposes to delete, as unnecessary, the prior instruction
to evaluate an esophageal spasm not amenable to dilation as a
stricture, because the proposed rating criteria for esophageal
stricture under DC 7203 now consider the frequency of dilatation.
Diagnostic Code 7205
For clarity, VA proposes to add a note with a non-exhaustive list
of conditions to which DC 7205, acquired diverticulum of the esophagus,
can apply. These conditions include pharyngo-esophageal (Zenker's)
diverticulum, as well as mid-esophageal and epiphrenic diverticula. The
existing instruction to rate conditions under this DC as esophageal
stricture (DC 7203) would remain without substantive change.
New Diagnostic Code 7206
VA proposes to add a new DC for rating gastroesophageal reflux
disease (GERD). Historically, VA has rated this condition analogously
to hiatal hernia (DC 7346). As discussed below, VA proposes to evaluate
hiatal hernia using the revised criteria found in DC 7203 (Esophagus,
stricture of) because the medical community now recognizes the close
relationship between the majority of symptoms associated with these
conditions. See Dakkak, supra. Similarly, VA proposes to evaluate GERD
using rating criteria in DC 7203 because these criteria consider
symptoms of esophageal obstruction and irritation, which are consistent
with the symptoms of GERD. D. Armstrong et al., ``Canadian consensus
conference on the management of gastroesophageal reflux disease in
adults: Update 2004,'' 19(1) Canadian J. of Gastroenterology, 15-35
(Jan. 2005).
New Diagnostic Code 7207
VA proposes to add Barrett's esophagus to Sec. 4.114 as a relevant
medical condition that the VASRD does not presently address. Barrett's
esophagus is characterized by the replacement of the normal squamous
epithelium of the distal esophagus by dysplastic or aberrant cells
(metaplasia), an anomalous cell overgrowth that may eventually become
cancerous. ``Barrett's Esophagus'' in National Digestive Diseases
Information Clearinghouse, National Institute of Diabetes and Digestive
and Kidney Diseases, NIH Publication No. 13-4546 (Feb. 2013), <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus">https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus</a> (last visited Oct. 06, 2021). The vast majority of patients
with Barrett's esophagus suffer no long-term effects other than the
inconvenience of periodic endoscopy to monitor the appearance of
adenocarcinoma. Kunal Jajoo, MD and John R. Saltzman, MD, ``Chapter 12:
Barret Esophagus,'' in ``Current Diagnosis & Treatment:
Gastroenterology, Hepatology, & Endoscopy'' (N.J. Greenberger, et al.
eds., 2d ed. 2012), available at <a href="http://accessmedicine.mhmedical.com/content.aspx?bookid=390&Sectionid=39819242">http://accessmedicine.mhmedical.com/content.aspx?bookid=390&Sectionid=39819242</a> (last visited Oct. 06,
2021). Various medical texts describe periodic surveillance and acid
suppression as adequate to manage the disease. Id. This condition is
usually a long-term complication of GERD. ``Barrett's Esophagus,''
supra.
If a veteran with Barrett's esophagus also has stricture, VA
proposes to evaluate the condition under DC 7203 (Esophagus, stricture
of). This is consistent with the prohibition against pyramiding under
38 CFR 4.14. If, however, esophageal stricture is not present, VA
proposes to evaluate Barrett's esophagus based on its progression
toward cancer. Specifically, VA proposes a 30-percent evaluation for
more advanced presentations (known as high-grade dysplasia), documented
by pathologic diagnosis. VA proposes a 10-percent evaluation for less
advanced presentations (known as low-grade dysplasia). High-degree
dysplasia represents a higher risk of disease and requires closer
surveillance, such as more frequent endoscopy, biopsy, etc., and in
some cases preemptive esophagectomy for adenocarcinoma. See M.S. Dar et
al., ``Can extent of high grade dysplasia in Barrett's esophagus
predict the presence of adenocarcinoma at esophagectomy?'' 52 Gut 486-
89 (2003). Low-degree dysplasia requires at least yearly endoscopy with
biopsy. Id. The symptomatology of patients with Barrett's esophagus is
indistinguishable from patients with GERD; thus, the rating of 30
percent is more consistent with higher degree of obstruction, while
those at 10 percent have mild esophageal discomfort manageable with
medications. See Jajoo, supra.
In addition to the above rating criteria, VA proposes to add a note
to evaluate any developing malignancies under DC 7343 (Malignant
neoplasms of the digestive system, exclusive of skin growths). VA
proposes a second note to evaluate any residuals from successful
treatment as DC 7203 (Esophagus, stricture of).
Other Digestive Disorders
Diagnostic Code 7301
VA proposes new rating criteria that consider both alimentary
support (such
[[Page 1526]]
as parenteral nutrition or dietary modification) and recurrent
obstruction. Under the present rating criteria, VA assigns ratings of
50, 30, 10, or 0 percent under DC 7301 based on whether peritoneal
adhesions are ``severe,'' ``moderately severe,'' ``moderate,'' or
``mild.'' These terms are generic and undefined and may lead to
inconsistent evaluations. Further, the rating criteria do not fully
address the complexities of this condition, which may require
intravenous nutrition and may not be repairable.
The current DC 7301 provides for a maximum 50-percent rating.
However, as some adhesions do not respond to treatment or require
nutritional support, VA intends to expand DC 7301 to include an 80-
percent evaluation. Under the proposed criteria, VA would assign an 80-
percent evaluation for persistent (continuous) partial bowel
obstruction that is either inoperable and otherwise refractory to
treatment or requires TPN for obstructive symptoms.
The 0-percent evaluation is currently described as ``mild'' without
additional criteria, explanation, or definition. VA proposes to re-
define the 0-percent evaluation by deleting ``mild'' and clarifying the
criteria as ``a history of peritoneal adhesions, currently
asymptomatic''. VA proposes to amend the 10-percent evaluation, and
assign it for symptomatic adhesions, persisting or recurring after
surgery, trauma, inflammatory disease process such as chronic
cholecystitis or Crohn's disease, or infection, which includes at least
one of the symptoms identified in the current VASRD (e.g., abdominal
pain, nausea, vomiting, colic, constipation, or diarrhea). VA proposes
to amend the 30-percent evaluation, and assign it for documented
symptomatic adhesions that meet the criteria for a 10-percent
evaluation, but also require medically-directed dietary modification
other than TPN. The current rating criteria provide a 50-percent rating
for symptomatology warranting inpatient care (e.g., severe peritonitis,
ruptured appendix, perforated ulcer, or an operation with drainage). VA
proposes to amend the 50-percent evaluation and assign it for
documented symptomatic adhesions requiring hospitalization at least
once per year, which also require medically-directed dietary
modification, other than TPN, and at least one of the following:
Diarrhea, constipation, colic, abdominal pain, nausea, or vomiting.
Currently, diagnostic code 7301 includes a note stating that
ratings for adhesions only apply with a history of operative,
traumatic, or infectious process and in the presence of at least two of
the listed symptoms. This note indicates that VA would evaluate
peritoneal adhesions caused by surgery, trauma, or infection. However,
diagnostic codes 7310 (Stomach, injury of, residuals) and 7317
(Gallbladder, injury of) provide instructions to rate analogously to
diagnostic code 7301 in certain cases. VA proposes to delete the
current note to clarify that no adhesions are necessary when evaluating
stomach or gallbladder injuries under DC 7301. VA would include in the
title of diagnostic code 7301 the language indicating that peritoneal
adhesions must be due to surgery, trauma, disease, or infection.
New Diagnostic Code 7303
As noted in the discussion regarding current Sec. 4.111, VA
proposes to add a DC entitled ``Chronic complications of upper
gastrointestinal surgery,'' which includes the need for parenteral or
enteral nutrition and the presence of chronic residual pain, motility
issues, and dumping syndrome. Existing codes for these conditions
(e.g., DCs 7308-7310) would refer rating personnel to the new code, DC
7303, when appropriate. This proposed DC would contain evaluation
criteria based on the criteria contained in existing DCs 7308-7310.
However, VA is retaining the individual DCs so VA may continue to track
specific claims and outcomes.
VA notes that existing DCs relevant to these conditions provide
ratings at 20, 40, and 60 percent. As with other DCs, VA assigns these
ratings when the disability level is mild, moderate, or severe,
respectively. To better accommodate the various complications that
arise with upper gastrointestinal surgery, VA proposes to change and
expand the disability levels to 0, 10, 30, 50, and 80 percent. This
change would not automatically impact any individuals with current
disability ratings under existing DCs. If a Veteran's disability rating
would be reduced under the amended version of DC 7303, no change in
compensation would occur unless the Veteran applied for a change or
reevaluation is otherwise warranted and the Veteran's disability is
shown to have improved. See 38 U.S.C. 1155. If the Veteran's disability
rating would increase under the amended version of DC 7303, the Veteran
could reapply for that increase.
VA proposes to assign a 0-percent rating for asymptomatic, post-
operative status to ensure that rating personnel understand when a
noncompensable evaluation is appropriate. VA proposes a 10-percent
rating when ongoing medical treatment manages either nausea or
vomiting. This new category would allow VA to compensate those
individuals whose effective treatment may preclude outward symptoms,
but who nevertheless experience mild impairment due to the need for the
treatment itself.
Current ratings provide a 20-percent rating when the level of
disability is mild. With the proposed addition of the 10-percent
disability level, VA proposes to eliminate the 20-percent disability
level and instead evaluate individuals with 2 or more of the following
symptoms as 30-percent disabled: (1) Vomiting two or more times per
week or vomiting not controlled by medical treatment; (2) discomfort or
pain within an hour of eating and requiring oral ongoing dietary
modification; or (3) three to five watery bowel movements per day every
day.
VA proposes to assign the next level of disability, 50-percent,
when any of the following continued symptoms exist: (1) Daily vomiting
not controlled by oral dietary modification or medication; (2) six or
more watery bowel movements per day every day or explosive bowel
movements that are difficult to predict or control; (3) post-prandial
(meal-induced) light-headedness (syncope) with sweating, the need for
medications (such as octreotide) specifically to treat complications of
upper gastrointestinal surgery, including dumping syndrome or delayed
gastric emptying (requiring promotility agents) following esophageal or
stomach surgery.
VA proposes an 80-percent evaluation for complete dependence on TPN
(i.e., required continuous total parenteral nutrition) or tube feeding
lasting for a period longer than 30 consecutive days in the past 6
months. Although some dependence on nutritional support such as TPN or
tube feeding is expected immediately following surgery, a duration
lasting longer than 30 consecutive days post-operatively is excessive
and reflects a more severe ongoing disability picture. This evaluation
is consistent with other disability ratings which require similar
levels of nutritional support (e.g., TPN).
Because of its differing presentation, VA proposes to include Note
(1), which instructs rating personnel to evaluate complications
following intestinal resection under DC 7328 (Intestine, small,
resection, dysfunction or malabsorption). VA also proposes to include
Note (2), directing that rating personnel evaluate vitamin/mineral
deficiencies associated with pancreatic surgery under the appropriate
vitamin/mineral deficiency code if a higher evaluation would result.
Finally, to further assist rating personnel in accurately applying DC
7303, VA
[[Page 1527]]
intends to include Note (3), which indicates that this DC includes
operations performed on the esophagus, stomach, pancreas, and small
intestine, including bariatric surgery.
Diagnostic Codes 7304 Through 7306
At present, VA evaluates ulcers depending on their location under
the following DCs: DC 7304 (Gastric); DC 7305 (Duodenal); and DC 7306
(Marginal gastrojejunal). While ulcers may vary in location, they
produce the same array of symptoms and do not differ in functional
incapacity. Therefore, VA proposes to eliminate DCs 7305 and 7306 and
revise DC 7304, retitled ``Peptic ulcer disease,'' to include all
evaluations previously done under current DCs 7304, 7305, 7306.
In 1984, Drs. Barry J. Marshall, and J. Robin Warren reported
finding a curved bacillus, initially named Campylobacter pyloridis, and
subsequently classified as Helicobacter pylori (H. pylori), in biopsies
taken from patients with gastritis and peptic ulcers. B.J. Marshall and
J.R. Warren, ``Unidentified curved bacilli in the stomach of patients
with gastritis and peptic ulceration,'' Lancet 1(8390), 1311-15 (June
16, 1984). Drs. Marshall and Warren received the Nobel Prize for
Medicine and Physiology in 2005 for their discovery that peptic ulcer
disease (PUD) was primarily caused by H. pylori, a bacterium with
acidic affinity.
Numerous studies have since shown that the eradication of this
bacterium reduces ulcer recurrence and complications such as bleeding
and cancer. See E. Lew, ``Chapter 15. Peptic Ulcer Disease,'' in
``Current Diagnosis & Treatment: Gastroenterology, Hepatology, &
Endoscopy,'' (2d ed. 2012), <a href="http://accessmedicine.mhmedical.com/content.aspx?bookid=390&Sectionid=39819246">http://accessmedicine.mhmedical.com/content.aspx?bookid=390&Sectionid=39819246</a> (last visited Oct. 06,
2021). Studies have also shown that PUD is primarily related to either
H. pylori infection or, to a lesser degree, the use of NSAIDS. Id.
Other peptic ulcers are residuals of surgery (anastomotic or post-
operative gastric). See C. Avunduk, ``Chapter 28. Postgastrectomy
Disorders,'' in ``Manual of Gastroenterology: Diagnosis and Therapy,''
The management and outcome of PUD has been drastically changed by the
introduction of acid-suppressive and proton pump inhibitor (PPI)
therapy. Id. Improved hygiene and antibiotic use have also helped
drastically reduced the overall incidence of PUD. Id. VA proposes that
this code evaluate H. pylori, NSAID, anastomotic, and post-operative
gastric ulcers, including treatable conditions.
Currently, VA evaluates ulcers as ``mild,'' ``moderate,''
``moderately severe,'' ``severe,'' and ``pronounced.'' Although these
terms refer to common symptoms such as abdominal pain, vomiting, melena
(tarry stools), and weight loss, the criteria remain subjective and
vague, which may lead to inconsistent evaluations. For example, under
current DC 7305, VA assigns a 40-percent evaluation when the duodenal
ulcer is ``Moderately severe; less than severe but with impairment of
health manifested by anemia and weight loss; or recurrent
incapacitating episodes averaging 10 days or more in duration at least
4 or more times a year.'' What constitutes ``less than severe''
symptomatology or an ``incapacitating episode'' is not defined. To
better evaluate peptic ulcers, VA proposes to provide more specific
rating criteria which clearly identify the major symptoms associated
with PUD and evaluate the level of disability based on the presence of
these symptoms, their frequency, and any treatment or outcomes.
VA proposes to assign a 0-percent evaluation for a history of PUD
documented by endoscopy or X-ray. VA proposes a 20-percent evaluation
for episodes of abdominal pain, nausea, or vomiting lasting for 3 days
or more, occurring 3 times or less in the past 12 months, and the
symptoms are managed by daily prescribed medication.
Current criteria for a 40-percent evaluation under DC 7305 and 7306
focus on ``recurrent incapacitating episodes,'' or ``intercurrent
episodes of pain . . . [and] mild and transient episodes of vomiting or
melena.'' As noted above, VA intends to reduce or eliminate ambiguity
in its rating criteria by replacing vague terms such as ``recurrent,''
``transient,'' and ``incapacitating episodes'' with clear, objective
criteria. Therefore, VA proposes to assign a 40-percent evaluation for
episodes of abdominal pain, nausea, or vomiting lasting for 3 days or
more, occurring 4 or more times in the past 12 months.
VA intends to assign a 60-percent evaluation for continuous
abdominal pain with intermittent vomiting, recurrent hematemesis
(vomiting blood) or melena (tarry stools), and manifestations of anemia
which require hospitalization at least once in the past 12 months. The
requirement for hospitalization is indicative of severe disabling
effects of PUD, which is resistant to treatment and more disabling in
its outcome than the symptomatology in the 0-, 20-, and 40-percent
evaluation levels.
VA proposes to assign a 100-percent evaluation for 3 months after
surgical repair of a perforation or hemorrhage (Fitness for Work, K.
Palmer, I. Brown, J. Hobson, Oxford U Press 2013, page 438). According
to widely accepted occupational health reference and clinical
guidelines, the three-month period for recuperation is recommended in
cases of surgical repairs for perforated gastric ulcer or hemorrhage.
(T. Palmer, I. Brown, and J. Hobson, Fitness for Work, 5th ed. (2013)).
After three months, VA would determine the appropriate rating for
residuals using a mandatory VA examination, as stated in the note to DC
7304.
Diagnostic Code 7307
While effective treatment of gastritis requires identification of
the specific etiology (origin), the specific etiology has little
relevance to functional incapacity, as its symptoms are consistent.
Akiva J Marcus et al., ``Chronic Gastritis,'' Medscape (Jun 07, 2019),
<a href="http://emedicine.medscape.com/article/176156-overview">http://emedicine.medscape.com/article/176156-overview</a> (last visited
Oct. 06, 2021). Therefore, VA proposes to retitle DC 7307 from
``Gastritis, hypertrophic (identified by gastroscope)'' to the more
generalized term of ``Gastritis, chronic.'' VA intends to remove the
requirement for endoscopy (e.g., gastroscope) as it is burdensome,
unnecessary, or replaced by radiology. See K.R. McQuaid, ``Chapter 15.
Gastrointestinal Disorders,'' in ``Current Medical Diagnosis &
Treatment 2021,'' (M.A. Papadakis et al. eds. 2021), <a href="https://accessmedicine.mhmedical.com/book.aspx?bookID=2957#249360894">https://accessmedicine.mhmedical.com/book.aspx?bookID=2957#249360894</a> (last
visited Oct. 06, 2021). VA also proposes to add a note that lists some
of the conditions to which this DC applies to help ensure consistent
usage.
The medical community recognizes the symptomatology and functional
incapacity associated with chronic gastritis is consistent with PUD.
Id. Therefore, VA proposes to remove the existing rating criteria and
replace it with a directive to evaluate the condition as a form of PUD
under DC 7304.
Diagnostic Code 7308
Postgastrectomy syndromes (DC 7308) are complications of surgery on
the stomach. Anatomic and physiological changes introduced by gastric
surgery result in changes in the motor functions of the stomach,
including disturbances in the gastric reservoir function, the
mechanical-digestive function, and the transporting function. See
Eagon, J.C., et al. Postgastrectomy syndromes. Surg Clin North Am. 1992
Apr;72(2):445-65.
[[Page 1528]]
(last visited Oct. 06, 2021) <a href="https://www.sciencedirect.com/science/article/pii/S0039610916456896?via%3Dihub">https://www.sciencedirect.com/science/article/pii/S0039610916456896?via%3Dihub</a>. Therefore, VA proposes to
remove the current rating criteria and direct rating personnel to use
the new criteria of DC 7303 (Chronic complications of upper
gastrointestinal surgery).
Diagnostic Code 7309
Currently, DC 7309 (Stomach, stenosis of) directs rating personnel
to evaluate it as gastric ulcer, DC 7304. Although this condition is
most often a complication of upper gastrointestinal surgery, it less
commonly may be a complication of PUD. Jin Hyoung Kim, MD, et al.,
``Fluoroscopically Guided Balloon Dilation for Benign Anastomotic
Stricture in the Upper Gastrointestinal Tract,'' 9 Korean J. Radiology
4 (2008). As such, VA proposes to direct rating personnel to evaluate
this condition under either DC 7303 (Chronic complications of upper
gastrointestinal surgery) or DC 7304 (Peptic ulcer disease).
Diagnostic Code 7310
Currently, DC 7310 directs rating personnel to evaluate injuries to
the stomach using the criteria of DC 7301 (Peritoneum, adhesion of).
However, certain gastrointestinal procedures can also result in injury
to the stomach, as well as such neighboring viscera as the pancreas and
intestines. Therefore, VA proposes to amend the existing direction to
state that rating personnel should continue to evaluate pre-operative
injuries to the stomach using the criteria of DC 7301 (Peritoneum,
adhesions of, due to surgery, trauma, disease, or infection), while
they should evaluate post-operative injuries under the new DC 7303
(Chronic complications of upper gastrointestinal surgery). VA proposes
to further amend the instruction for pre-operative injuries to clarify
that no adhesions are necessary when evaluating stomach injuries under
DC 7301.
Diagnostic Code 7312
The current DC 7312 is entitled ``Cirrhosis of the liver, primary
biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis.'' As
the two latter conditions are forms of cirrhosis, VA proposes to
simplify the title of DC 7312 to ``Cirrhosis of the liver.'' Currently,
VA evaluates conditions within the scope of DC 7312 using physical
status, functional limitation, laboratory findings, and imaging
studies.
Since last modifying this rating criteria, the medical community
has increasingly accepted the Model for End-Stage Liver Disease (MELD),
a mathematical model developed by the Mayo Clinic to predict survival
and outcome in liver disease. P.S. Kamath et al., ``Model for End-Stage
Liver Disease (MELD),'' 45 Hepatology 797 (2007); David Wolf, <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.21563">https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.21563</a> (last
visited Oct. 06, 2021). The MELD score is used throughout the United
States to prioritize and stage patients waiting for liver transplants.
It also serves as the Social Security Administration's basis for the
SSA Chronic Liver Disease (SSA CLD) score used for calculating the
severity of chronic liver disease. Disability Evaluation Under Social
Security: Blue Book, Chapter 5.00 Digestive System--Adult, section 505:
Chronic Liver Disease, Paragraph G, (Sept. 2008). The MELD score is
well suited to rating disabilities because of its high correlation with
clinical features, including functional status. The MELD also predicts
prognosis (disease severity and mortality) in patients with liver
cirrhosis and alcoholic hepatitis. F. Botta et al., ``MELD Scoring
System in patients with liver cirrhosis and residual liver function,''
52 Gut 134-39 (2003), <a href="http://gut.bmj.com/content/52/1/134.full.pdf+html">http://gut.bmj.com/content/52/1/134.full.pdf+html</a>
(last visited Oct. 06, 2021). Also, see Milan Sheth et al., ``Utility
of the Mayo End-Stage Liver Disease (MELD) score in assessing prognosis
of patients with alcoholic hepatitis,'' 2 BMC Gastroenterology 2
(2002), <a href="http://www.biomedcentral.com/content/pdf/1471-230x-2-2.pdf">http://www.biomedcentral.com/content/pdf/1471-230x-2-2.pdf</a>
(last visited Oct. 06, 2021). Therefore, VA is proposing to include it
in the rating criteria for cirrhosis alongside analogous clinical signs
and symptoms.
The following three values form the MELD score: (1) International
normalized ratio (INR) (prothrombin time); (2) serum bilirubin; and (3)
serum creatinine. The mathematical equation below uses these values to
produce a score between 6 and 40, with 40 indicating a gravely ill
person with high risk of mortality.
MELDScore = 10 * ((0.957 * ln(Creatinine)) + (0.378 * ln(Bilirubin)) +
(1.12 * ln(INR))) + 6.43
See Wolf, supra at <a href="https://emedicine.medscape.com/article/185856-overview#showall">https://emedicine.medscape.com/article/185856-overview#showall</a> (last visited Oct. 06, 2021). The scores from 6 to 15
correlate best with expected survival. Id. VA intends the rating
criteria to list ranges of MELD scores that correspond to various
levels of liver impairment correlated with clinical findings.
As the MELD score may not always be available, VA also proposes to
include alternative means of determining functional impairment using
clinical findings pertaining to physical status, functional incapacity,
laboratory findings, and imaging studies.
VA intends to assign a 0-percent evaluation for a history of liver
disease without current symptoms. Consistent with the current
evaluation under DC 7312, VA would assign a 10-percent evaluation for
either a MELD score greater than 6 but less than 10, or evidence of
weakness, anorexia, abdominal pain, or malaise.
VA currently assigns a 30-percent evaluation for portal
hypertension and splenomegaly, with weakness, anorexia, abdominal pain,
malaise, and at least minor weight loss. VA proposes to eliminate the
reference to ``minor weight loss'' and assign a 30-percent evaluation
for either a MELD score of 10 or 11, or; portal hypertension
(splenomegaly or ascites) with weakness, anorexia, abdominal pain, or
malaise, which would fully reflect the severity of the disability.
The current DC 7312 assigns either a 50- or 70-percent evaluation
depending on the number of episodes of ascites, hepatic encephalopathy,
or hemorrhage from varices or portal gastropathy (erosive gastritis).
VA proposes to eliminate the 50- and 70-percent levels of evaluation
and assign a 60-percent evaluation for a MELD score greater than 11 but
less than 15, or daily fatigue with at least 1 episode in the last year
of variceal hemorrhage, portal gastropathy, or hepatic encephalopathy.
This proposal would ensure VA rates individuals for chronic
symptomatology, as well as episodic flare-ups.
VA proposes a 100-percent evaluation for either a MELD score of at
least 15, or constant daily debilitating symptoms and generalized
weakness with at least one of the following: Ascites (fluid in the
abdomen), a history of spontaneous bacterial peritonitis,
encephalopathy, variceal hemorrhage, coagulopathy, portal gastropathy,
hepatopulmonary or hepatorenal syndrome.
In addition to the above rating criteria, VA proposes to add three
notes. Note 1 would instruct rating personnel to evaluate
hepatocellular carcinoma occurring with cirrhosis under DC 7343
(Malignant neoplasms of the digestive system, exclusive of skin
growths) rather than cirrhosis. Note 2 would indicate that biochemical
studies, imaging studies, or biopsies must confirm liver dysfunction,
including hyponatremia, thrombocytopenia, and/or coagulopathy in order
to receive an evaluation under DC 7312. Note 3 would instruct rating
personnel to
[[Page 1529]]
evaluate the condition based on symptomatology where the evidence does
not contain a MELD score.
Diagnostic Code 7314
DC 7314 is currently titled ``Cholecystitis, chronic,'' which is a
persistent swelling and irritation of the gallbladder. The gallbladder
is a sac adjacent to the liver that stores bile, a substance the liver
makes and the intestines use to digest fats. See ``Gallstones,''
National Digestive Diseases Information Clearing House, NIH Publication
No. 13-2897 (November 2017), <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones">https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones</a> (last visited Oct. 06, 2021).
The symptoms of chronic cholecystitis are similar to other diseases of
the biliary tract (the name for the liver and gallbladder ducts, which
are related to the production, storage, and use of bile). See G.
Paumgartner and N.J. Greenberger, ``Chapter 53. Gallstone Disease,'' in
``Current Diagnosis & Treatment: Gastroenterology, Hepatology, &
Endoscopy,'' (N.J. Greenberger, et al. eds., 2d ed. 2012), <a href="http://accessmedicine.mhmedical.com/content.aspx?bookid=390&Sectionid=39819290">http://accessmedicine.mhmedical.com/content.aspx?bookid=390&Sectionid=39819290</a>
(last visited Oct. 06, 2021). Therefore, VA proposes to expand this DC
to cover all chronic diseases of the biliary tract by retitling it
``Chronic biliary tract disease.''
Currently, DC 7314 provides 30-, 10-, and 0-percent evaluations. VA
assigns a 30-percent evaluation if the condition is severe, with
frequent attacks of gallbladder colic. VA assigns a 10-percent
evaluation if the condition is moderate, with gallbladder dyspepsia,
confirmed by X-ray, and with infrequent attacks (not over 2 or 3 a
year) of gallbladder colic, with or without jaundice. VA assigns a 0-
percent evaluation if the condition is mild.
VA proposes to eliminate the subjective terms in the existing
criteria as a way of reducing inconsistent evaluations, but continue
rating these conditions on the frequency of ``attacks.'' To provide
more objectivity to the rating process, VA proposes to specify the
number of episodes and associated symptoms required for each level of
disability.
VA proposes to assign a 30-percent evaluation for 3 or more
clinically documented attacks of right upper quadrant pain with nausea
and vomiting in the past 12 months; or when biliary tract strictures
require dilatation at least once in the past 12 months. VA would assign
a 10-percent evaluation for 1 or 2 clinically documented attacks of
right upper quadrant pain with nausea and vomiting in the past 12
months. Under this proposal, VA would assign a 0-percent evaluation
when the condition is asymptomatic and there is no history of a
clinically documented attack of right upper quadrant pain with nausea
and vomiting in the past 12 months.
In addition to the above criteria, VA proposes to note the
following non-exhaustive list of conditions to which this DC applies:
Cholangitis, biliary strictures, Sphincter of Oddi dysfunction, bile
duct injury, and choledochal cyst. This note would also direct
evaluating primary sclerosing cholangitis under the renamed DC 7345
(Chronic liver disease without cirrhosis), due to shared
symptomatology.
Diagnostic Code 7315
DC 7315, Chronic choleslithiasis, currently directs rating
personnel to evaluate this condition under DC 7314 (Cholecystitis,
chronic). VA does not propose any changes other than amending the
instruction to reflect the retitling of DC 7314.
Diagnostic Code 7316
DC 7316, chronic cholangitis, is one of several related conditions
currently evaluated under DC 7314 (Cholecystitis, chronic). VA proposes
to track this disability under DC 7314, so it proposes to eliminate DC
7316. This removal would not, in and of itself, alter existing
evaluations or grants of service connection. Rather, VA would modify
the individual's record to reflect the grant of service connection
under DC 7314 instead of DC 7316.
Diagnostic Code 7317
Currently, VA directs rating personnel to rate gallbladder injuries
under DC 7301 (Peritoneum, adhesions of). However, that code does not
address all likely effects of injuries to the gallbladder. Therefore,
VA proposes to evaluate this condition under whichever of the following
DCs most effectively demonstrates the level of functional limitation:
7301 (Peritoneal adhesions), or 7314 (Chronic gallbladder and biliary
tract disease), or 7318 (Cholecystectomy (gallbladder removal)
complications of (such as strictures and biliary leaks)). VA also
proposes to correct a typographical error, changing the title from
``Gall bladder, injury of,'' to ``Gallbladder, injury of.''
Further, VA proposes to add a note to DC 7317, clarifying that no
adhesions are necessary when evaluating gallbladder injuries under DC
7301.
Diagnostic Code 7318
Currently, DC 7318 is titled, ``Gall bladder, removal of.'' As with
DC 7317, VA is correcting the spelling to ``Gallbladder.'' However, the
current title does not fully express the scope of complications of
gallbladder removal. Also, the medical term for gallbladder removal is
cholecystectomy. As rating personnel may encounter either term in
medical records, VA proposes to retitle this DC as ``Cholecystectomy
(gallbladder removal), complications of (such as strictures and biliary
leaks).''
VA currently assigns a 30-percent evaluation for severe symptoms, a
10-percent evaluation for mild symptoms, and 0-percent evaluation if
the condition is asymptomatic. Using subjective terms ``severe'' and
``mild'' without indicating specific symptoms may contribute to
inconsistent evaluations.
Therefore, VA proposes new criteria that enumerate the
complications and symptoms, to include abdominal pain and diarrhea,
resulting from the removal of the gallbladder. See Steen W. Jensen, MD,
``Postcholecystectomy Syndrome,'' Medscape Reference (Jul 24, 2020),
<a href="http://emedicine.medscape.com/article/192761-overview">http://emedicine.medscape.com/article/192761-overview</a> (last visited
Oct. 06, 2021). Specifically, VA proposes to assign a 0-percent
evaluation for a cholecystectomy without symptoms. VA proposes a 10-
percent evaluation for intermittent (stopping and starting at
intervals) abdominal pain and diarrhea characterized by one to two
watery bowel movements per day. VA proposes a 30-percent evaluation for
recurrent abdominal pain most often occurring after a meal (post-
prandial) or at night time (nocturnal) and chronic diarrhea
characterized by three or more watery bowel movements per day.
Diagnostic Code 7319
DC 7319 is currently titled ``Irritable colon syndrome (spastic
colitis, mucous colitis, etc.).'' However, the medical community now
refers to ``irritable colon syndrome'' as ``irritable bowel syndrome.''
Therefore, VA proposes to retitle this code ``Irritable Bowel Syndrome
(IBS)'' to more accurately describe the condition to which it applies.
The current evaluation levels under this DC are 30, 10, and 0-
percent. VA assigns a 30-percent evaluation if the condition is severe,
``with diarrhea or alternating diarrhea and constipation, with more or
less constant abdominal distress.'' VA assigns a 10-percent evaluation
if the condition is moderate, with ``frequent episodes of bowel
disturbance with abdominal distress.'' VA assigns a 0-percent
evaluation if the condition is mild, with ``disturbances of bowel
function with occasional episodes of abdominal distress.''
[[Page 1530]]
VA proposes to replace current criteria with more objective
criteria derived from the Rome IV criteria for IBS. See Brian Lacy,
``Bowel Disorders,'' Gastroenterology, 150: 1393-1407 (2016).
Specifically, VA proposes to assign a 10-percent evaluation when an
individual has abdominal pain related to defecation at least once
during the previous 3 months. In addition, this person must have had
two or more of the following: Change in stool frequency, change in
stool form, altered stool passage (straining and/or urgency),
mucorrhea, abdominal bloating, or subjective distension.
VA proposes to assign a 20 percent evaluation when an individual
has abdominal pain for at least 3 days per month during the previous 3
months. Additionally, this individual must have had two or more of the
following: Change in stool frequency, change in stool form, altered
stool passage (straining and/or urgency), mucorrhea, abdominal
bloating, or subjective distension.
VA proposes a 30-percent evaluation when an individual has at least
one episode per week of abdominal pain associated with defecation
during the previous 3 months. Further, the individual must have
exhibited two or more of the following: Change in stool frequency,
change in stool form, altered stool passage (straining and/or urgency),
mucorrhea, abdominal bloating, or subjective distension.
VA also proposes to add one note to DC 7319 to assist rating
personnel in applying these criteria. This note would clarify that this
DC pertains to functional digestive disorders (38 CFR 3.317), such as
dyspepsia, functional bloating and constipation, and diarrhea. Rating
personnel may evaluate other symptoms of functional digestive disorders
not found under this code using new DC 7356 (gastrointestinal
dysmotility syndrome), following the general principles of Sec. Sec.
4.14 and 4.114.
Proposed Elimination of DC 7321, Amebiasis, DC 7322, Dysentery,
Bacillary, and DC 7324, Distomiasis, Intestinal or Hepatic
All three diagnostic codes refer to conditions that are infectious
in nature. There are two main types of dysentery: (1) Bacillary
dysentery or shigellosis that is caused by shigella bacteria, and (2)
amebic dysentery or amebiasis that is caused by an ameba (single-celled
parasite) called Entamoeba histolytica. DC 7324 is currently titled
``Distomiasis, intestinal or hepatic'' and refers to the early 20th
century medical texts that used this now outdated term when referring
to an intestinal parasitosis caused by trematodes or flukes (Fasciola
hepatica).
VA published a final rule in the Federal Register at 84 FR 28227 on
June 18, 2019, to amend 38 CFR 4.88a and 4.88b, the portion of the
VASRD dealing with infectious diseases, immune disorders, and
nutritional deficiencies. In this final rule, VA introduced two new
diagnostic codes, DC 6334 (Shigella infections) and 6320 (Parasitic
diseases) otherwise not specified. DC 6334 addresses conditions
previously covered under DC 7322 and DC 6320 addresses conditions
previously covered under DC 7321 and DC 7324. Therefore, VA proposes to
delete DC 7321 (Amebiasis), DC 7322 (Dysentery, bacillary), and DC 7324
(Distomiasis, intestinal or hepatic) from the portion of the rating
schedule that addresses the digestive system.
This removal would not, in and of itself, alter existing
evaluations or grants of service connection. Rather, VA would modify
the individual's record to reflect the grant of service connection
under the appropriate diagnostic code.
Diagnostic Code 7323
VA currently evaluates ulcerative colitis (DC 7323) at 100, 60, 30,
or 10 percent. VA assigns a 100-percent evaluation if the condition is
pronounced, resulting in marked malnutrition, anemia, and general
debility, or if there are serious complications, such as liver abscess.
A severe condition, consisting of numerous attacks yearly and
malnutrition, with health only fair during remissions, warrants a 60-
percent evaluation. VA assigns a 30-percent evaluation if the condition
is moderately severe, with frequent exacerbations. A moderate
condition, with infrequent exacerbations, warrants a 10-percent
evaluation.
Ulcerative colitis is one of the primary forms of inflammatory
bowel disease. While specific inflammatory bowel diseases merit
different treatment, they share many common symptoms and resulting
functional impairments. ``Ulcerative Colitis,'' University of Maryland
Medical Center, Inflammatory Bowel Disease Center (Apr. 23, 2013),
<a href="http://www.umm.edu/programs/ibd/services/colitis">http://www.umm.edu/programs/ibd/services/colitis</a> (last visited Oct. 06,
2021). Therefore, VA proposes to remove the existing criteria and
replace it with an instruction to rate the condition using the criteria
proposed for the newly created DC 7326, Crohn's disease, another form
of inflammatory bowel disease.
Diagnostic Code 7325
Currently, VA evaluates chronic enteritis using the criteria under
DC 7319 (Irritable colon syndrome). However, this process may not
account for the most likely or most disabling of symptoms. Therefore,
VA proposes to direct rating personnel to rate these conditions under
either the revised DC 7319 (Irritable bowel syndrome) or DC 7326
(Crohn's disease), whichever is most appropriate.
Diagnostic Code 7326
Currently, DC 7326 is titled ``Enterocolitis, chronic.'' VA
proposes to retitle it, ``Crohn's disease or undifferentiated form of
inflammatory bowel disease'' to account for the array of inflammatory
intestinal conditions that have similar symptoms and functional
outcomes.
Currently, VA directs rating personnel to evaluate this condition
using the criteria provided under DC 7319 (Irritable colon syndrome).
However, the medical community has determined that inflammatory bowel
conditions are distinct from irritable bowel conditions (see DC 7319)
and are characterized by inflammation of unknown etiology that can
affect any portion of the gastrointestinal tract from the mouth to the
perianal area. See ``IBS and IBD: Two Very Different Disorders,''
Crohn's & Colitis Foundation of America (Oct. 2019), <a href="https://www.crohnscolitisfoundation.org/what-is-ibd/ibs-vs-ibd">https://www.crohnscolitisfoundation.org/what-is-ibd/ibs-vs-ibd</a> (last visited
Oct. 06, 2021). See also ``What Is Crohn's Disease?'' Crohn's & Colitis
Foundation of America, <a href="http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/">http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/</a> (last visited Oct. 06,
2021). Transmural inflammation, coupled with the number of potentially
affected organs, produces various signs and symptoms and corresponding
functional outcomes.
Therefore, VA proposes new rating criteria based on the Truelove
and Witts criteria for inflammatory bowel disease, to include Crohn's
disease and ulcerative colitis (DC 7323). A. Kornbluth and D. Sachar,
``The Practice Guidelines for Ulcerative Colitis of the American
College of Gastroenterology,'' 105 a.m. J. Gastroenterology, 501-23
(2010). These criteria focus on the frequency and severity of the
hallmark clinical symptom, bloody diarrhea with rectal urgency. Id. In
addition to these criteria, VA proposes to evaluate the severity of the
disease based on the number and frequency of exacerbations, as well as
the level of treatment used to control the disease.
[[Page 1531]]
According to the Truelove and Witts criteria, mild symptomatology
involves fewer than four bowel movements per day with infrequent rectal
bleeding; severe symptomatology involves six or more bowel movements
per day with frequent rectal bleeding. VA therefore proposes to assign
a 10-percent evaluation for minimal or mild symptomatic disease that is
managed with oral or topical agents (other than immunosuppressants or
other biologic agents) and is characterized by recurrent abdominal pain
with 3 or less daily episodes of diarrhea and no signs of systemic
toxicity.
VA proposes a 30-percent evaluation for mild to moderate disease,
with recurrent abdominal pain, with 3 or less episodes of diarrhea per
day, minimal signs of toxicity (fever, tachycardia, or anemia), and
symptoms managed with topical or oral agents.
VA proposes to assign a 60-percent evaluation for moderate disease
with recurrent abdominal pain, 4 to 5 daily episodes of diarrhea, and
intermittent signs of toxicity (such as fever, tachycardia, or anemia),
and requiring immunosuppressants or other biologic agents on an
outpatient basis.
VA proposes a 100-percent evaluation for all cases of severe
inflammatory bowel disease that are unresponsive to treatment, require
hospitalization at least annually, and result in either an inability to
work or are characterized by recurrent abdominal pain associated with
at least 2 of the following features: 6 or more episodes per day of
diarrhea, 6 or more episodes per day of rectal bleeding, recurrent
episodes of rectal incontinence, or recurrent abdominal distention. VA
also proposes to include three notes to assist rating personnel in
applying DC 7326. The first note would direct that, following colectomy
or colostomy with persistent or recurrent residuals, rating personnel
should evaluate the condition under DC 7326 or DC 7329 (Intestine,
large, resection of), whichever DC provides the highest rating. The
second note would state that endoscopy or radiologic studies must
confirm the diagnosis of IBD for VA rating purposes to ensure the
proper application of this code. William A. Rowe et al., ``Inflammatory
bowel disease,'' Medscape Reference (Apr 10, 2020), <a href="http://emedicine.medscape.com/article/179037-overview">http://emedicine.medscape.com/article/179037-overview</a> (last visited Oct. 06,
2021). Finally, the third note would inform personnel that inflammatory
bowel disease may affect any segment of the gastrointestinal tract from
the mouth to the anus.
VA acknowledges that, generally, the use of the terms ``minimal,''
``mild,'' ``moderate,'' and ``severe'' may lead to inconsistent
evaluations due to their subjectivity. However, VA proposes to provide
more clarity in the assignment of ratings by defining these terms by
the characteristics and criteria listed for each level under DC 7326.
Diagnostic Code 7327
Currently, DC 7327 is titled ``Diverticulitis.'' VA proposes to
retitle it as ``Diverticulitis and diverticulosis'' to account for
other conditions that rating personnel presently evaluate analogously
under this code.
In its present form, DC 7327 does not provide specific criteria for
diverticulitis but instead directs rating personnel to evaluate it as
irritable colon syndrome (DC 7319), peritoneal adhesions (DC 7301), or
ulcerative colitis (DC 7323), depending on the predominant disability
picture. However, these criteria do not sufficiently capture its
functional impairment. Therefore, VA proposes criteria specific to
diverticulitis, such as fever, abdominal pain, elevated white cell
count, the frequency of disabling episodes, the development of
abdominal complications, intestinal bleeding, and hospitalizations.
According to the National Institute of Diabetes and Digestive and
Kidney Disease, diverticulosis is quite common, especially in the aging
population. Survey data suggests while only about 35 percent of U.S.
adults age 50 years or younger have diverticulosis, individuals older
than age 60 are affected at a higher rate (58 percent). Furthermore,
research suggests that less than 5 percent of people with
diverticulosis would develop diverticulitis, but most people with
diverticulosis will never develop symptoms or problems. See
``Diverticular Disease,'' National Digestive Diseases Information
Clearing House, NIH Publication No. 13-1163 (May 2016), <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/diverticulosis-diverticulitis/definition-facts">https://www.niddk.nih.gov/health-information/digestive-diseases/diverticulosis-diverticulitis/definition-facts</a> (last visited Oct. 06, 2021).
Specifically, VA proposes assigning a 0-percent evaluation for
asymptomatic diverticulitis or diverticulosis; or a symptomatic
diverticulitis or diverticulosis that is managed by diet and
medication. VA proposes a 20-percent evaluation for diverticular
disease requiring hospitalization one or more times per year for
abdominal distress, fever, and leukocytosis (elevated white blood
cells) without associated hemorrhage, obstruction, abscess,
peritonitis, or perforation. VA proposes a 30-percent evaluation for
diverticular disease requiring hospitalization for abdominal distress,
fever, and leukocytosis one or more times the past 12 months, with at
least 1 of the following complications: Hemorrhage, obstruction,
abscess, peritonitis, or perforation. VA also proposes to include one
note to clarify that rating personnel should evaluate colectomy or
colostomy under either this DC or DC 7329 (Intestine, large, resection
of), whichever DC results in the highest evaluation.
Diagnostic Code 7328
VA currently evaluates resection of the small intestine as follows:
A 60-percent evaluation if the condition shows ``marked interference
with absorption and nutrition, manifested by severe impairment of
health objectively supported by examination findings, including
material weight loss;'' a 40-percent evaluation if the condition
produces ``definite interference with absorption and nutrition,
manifested by impairment of health objectively supported by examination
findings, including definite weight loss;'' and a 20-percent evaluation
if the condition is ``symptomatic, with diarrhea, anemia, and inability
to gain weight.''
These criteria contain vague terms, such as ``material,''
``definite,'' and ``marked.'' Also, the current criteria, based partly
on weight loss or the inability to gain weight, are no longer
appropriate because the availability of parenteral and supplemental
nutrition will ordinarily allow patients to maintain body weight.
Therefore, VA proposes to provide rating criteria that are both
more objective and more characteristic of the disabling effects of
resection of the small intestine in light of modern medicine. The new
criteria would consider the need for oral dietary supplementation or
parenteral nutrition and the presence of diarrhea and other symptoms.
Based on the current clinical guidelines and reflective of
functional outcomes of small intestine resection described below, VA
proposes to assign a 0-percent evaluation for asymptomatic individuals
with a history of resection of the small intestine. VA would assign a
20-percent evaluation for an individual who is status post intestinal
resection and experiences 4 or more episodes of diarrhea per day. VA
proposes a 40-percent evaluation when there is evidence of 4 or more
episodes of diarrhea per day resulting in undernutrition and anemia,
and the individual requires prescribed oral dietary supplementation and
continuous medication. VA proposes a 60-percent evaluation for
manifestations of undernutrition and anemia and
[[Page 1532]]
requiring prescribed oral dietary supplementation, continuous
medication and intermittent total parental nutrition (TPN). VA proposes
an 80-percent evaluation for manifestations of undernutrition and
anemia that require total parenteral nutrition.
Additionally, VA proposes to include an explanatory note stating
that this condition includes short bowel syndrome, mesenteric ischemic
thrombosis, and post-bariatric surgery complications with instructions
to consider a higher rating for short bowel syndrome with high-output
syndrome (including high-output stoma) under DC 7329 ``Intestine,
large, resection of.''
The average length of the adult human small intestine is
approximately 600 cm (236.22 in), as calculated from studies performed
on cadavers. According to Lennard-Jones and to Weser, the range extends
from 260 (102.4 in) to 800 cm (315 in).[1] Any disease, traumatic
injury, vascular accident, or other pathology that leaves less than 200
cm (78.7 in) of viable small bowel or results in a loss of 50 percent
or more of the small intestine places the patient at risk for
developing short-bowel syndrome. Short-bowel syndrome is a disorder
clinically defined by malabsorption, diarrhea, steatorrhea (fatty
stool), fluid and electrolyte disturbances, and malnutrition. The
common etiologic factor in all causes of short-bowel syndrome is the
functional or anatomic loss of extensive segments of small intestine so
that absorptive capacity is severely compromised. Burt Cagir, M.D.,
FACS, ``Short Bowel Syndrome,'' Medscape Reference (May 22, 2019),
<a href="https://emedicine.medscape.com/article/193391-overview#showall">https://emedicine.medscape.com/article/193391-overview#showall</a> (last
viewed Oct. 10, 2019). In some cases, short bowel syndrome can result
in high-output syndrome (including high-output stoma), in which the
increased elimination and reduced absorption in the colon produce an
imbalance in certain electrolytes. Therefore, VA intends to direct
rating personnel to consider whether they may assign a higher
evaluation under proposed DC 7329 (Intestine, large, resection of),
where VA provides for a 100-percent evaluation when a high-output
syndrome has resulted in more than 2 episodes of dehydration requiring
intravenous hydration in the past 12 months.
Diagnostic Code 7329
VA currently evaluates resection of the large intestine (DC 7329)
based on undefined criteria of whether symptoms are ``severe'' (40
percent), ``moderate'' (20 percent), or ``slight'' (10 percent). VA
proposes new rating criteria that replace these subjective terms with
more objective indicators based on the amount/level of resection, the
need for chronic intravenous hydration following surgery, and other
surgical outcomes, such as colostomy and ileostomy.
Specifically, VA proposes evaluations at the 10, 20, and 40 percent
levels for partial colectomy (resection of only part of the large
intestines). VA proposes a 10-percent evaluation for a partial
colectomy with reanastomosis (reconnection of the intestinal tube). VA
proposes a 20-percent evaluation for a similar level of resection
(partial colectomy), but loss of the ileocecal valve, which prevents
the flow of bacteria from the large intestine to the small intestine,
and with subsequent recurrent diarrhea of more than 3 times per day.
See ``Short Bowel Syndrome and Crohn's Disease,'' Crohn's & Colitis
Foundation of America, 3 (March 2018), <a href="https://www.crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/short-bowel-disease-crohns.pdf">https://www.crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/short-bowel-disease-crohns.pdf</a> (last visited Oct. 06, 2021). Without
the ileocecal valve, individuals may develop small-growth bacteria,
which manifest as diarrhea, bloating, nausea, and vomiting. Id.
VA proposes a 40-percent evaluation for a partial colectomy with
permanent colostomy (an opening in the abdominal wall that is made
during surgery). Individuals with colostomies must live with small bags
attached to their abdomen. These bags collect stool and individuals
must empty them. See ``Colostomy,'' in ``A.D.A.M. Medical
Encyclopedia,'' PubMed Health, U.S. National Library of Medicine (Oct.
05, 2021), <a href="http://www.nlm.nih.gov/medlineplus/ency/article/002942.htm">http://www.nlm.nih.gov/medlineplus/ency/article/002942.htm</a>
(last visited Oct. 06, 2021).
Additionally, VA proposes higher ratings, 60 and 100 percent, for
veterans with total colectomies, or complete removal of the large
intestines (colon). Total colectomy is a procedure most commonly done
to treat many diseases of the colon such as colon cancer, Crohn's
disease, ulcerative colitis, or massive abdominal trauma. One of the
major functions of the intact large intestine is to absorb water,
electrolytes, and vitamins. Following total colectomies, increased
amount of fluid may be excreted, resulting in a chronic salt and water
depletion, which can result in a number of metabolic changes. Christl
SU and Scheppach W., Metabolic consequences of total colectomy. Scand J
Gastroenterol Suppl. 1997;222:20-4. (last visited Oct. 06, 2021) In
some cases, total colectomy is performed in conjunction with ileostomy
surgery (small intestine known as the ileum). Permanent ileostomies are
created when the large intestine (colon) is damaged and needs removing.
Occasionally, and most frequently seen in cases with ileostomies,
individuals may experience ``high-output syndrome,'' in which the high
intestinal output increases the risk of dehydration and fluid-
electrolyte abnormalities, and seriously impairs the quality of life.
K. McDoniel et al., ``Use of clonidine to decrease intestinal fluid
losses in patients with high-output short bowel syndrome,'' 28 J. of
Parenteral Enteral Nutrition 4: 265-68 (July-Aug. 2004). <a href="https://www.ncbi.nlm.nih.gov/pubmed/15291409">https://www.ncbi.nlm.nih.gov/pubmed/15291409</a> (last visited Oct. 06, 2021)
To adequately compensate veterans with total colectomies, VA
proposes a 60-percent evaluation for a total colectomy without high
output syndrome. VA proposes a 100-percent evaluation for a total
colectomy with formation of ileostomy (permanent opening), high-output
syndrome, and more than 2 episodes of dehydration requiring intravenous
hydration in the past 12 months.
Diagnostic Code 7330
DC 7330 is currently titled ``Intestine, fistula of, persistent, or
after attempt at operative closure.'' However, this title does not
address the full range of intestinal fistulas. Therefore, VA proposes
to retitle this code as ``Intestinal fistulous disease, external,'' and
include a note explaining that this code applies to external fistulas
that have developed as a consequence of abdominal trauma, surgery,
radiation, malignancy, infection, or ischemia. David E. Stein, MD, et
al., ``Intestinal Fistulas Treatment and Management,'' Medscape
Reference (Mar 08, 2018), <a href="http://emedicine.medscape.com/article/179444-overview">http://emedicine.medscape.com/article/179444-overview</a> (last visited Oct 06, 2021).
Currently, the amount and frequency of fecal discharge determines
the evaluation under DC 7330. VA assigns a 100-percent evaluation if
fecal discharge is ``copious and frequent;'' a 60-percent evaluation
for discharge that is ``constant or frequent;'' and a 30-percent
evaluation for ``slight'' and ``infrequent.'' VA evaluates healed
fistulas as peritoneal adhesions. As previously noted, terms such as
``frequent'' and ``slight'' are too vague to allow for consistent
evaluations. Through this update, VA proposes to replace such
references with more specific and objective criteria.
Therefore, VA proposes new rating criteria which would account for
the
[[Page 1533]]
quantity of drainage from the fistula, as well as any need for
nutritional support. Specifically, VA proposes a 30-percent evaluation
for intermittent fecal discharge with persistent drainage that lasts
longer than 3 months in the past 12 months. VA proposes a 60-percent
evaluation for mandatory enteral nutritional support along with at
least one of the following: Daily drainage equivalent to 3 or less
standard ostomy bags (sized 130 cubic centimeters); or requiring fewer
than 10 pad changes per days; or a Body Mass Index (BMI) between 16 and
18 with persistent drainage of any amount for more than 2 months in the
past 12 months. VA proposes a 100-percent evaluation for mandatory
total parenteral nutrition; or enteral nutrition along with at least
one of the following: Daily discharge equivalent to 4 or more standard
ostomy bags (sized 130 cubic centimeters); or requiring 10 or more pad
changes per days; or both a BMI less than 16 and persistent draining
for more than 1 month during the past 12 months.
Diagnostic Code 7332
Current DC 7332 applies to impairment of sphincter control of the
rectum and anus. VA proposes to include a note to ensure that rating
personnel understand that such control may include either the inability
to retain or the inability to expel stool at an appropriate time and
place.
Currently, VA assigns: A 100-percent evaluation if the loss of
sphincter control is complete; a 60-percent evaluation if there is
``extensive leakage and fairly frequent involuntary bowel movements;''
a 30-percent evaluation for occasional involuntary bowel movements,
such that changing a pad is necessary; a 10-percent evaluation for
constant slight, or occasional moderate, leakage; and a 0-percent
evaluation if the condition is healed or slight, without leakage. These
criteria contain numerous indefinite terms, such as ``extensive,''
``frequent,'' ``occasional,'' and ``slight,'' which are open to
interpretation.
Therefore, VA proposes to use the widely-recognized Cleveland
Clinic Incontinence Scale (CCIS), a standardized, evidence-based
measure that accounts for difficulties with retention and expulsion of
stool. This scale determines the severity of sphincter impairment by
assigning a score between 0 (absent) and 4 (daily) in each of the
following 5 categories: Incontinence to gas, incontinence to liquid,
incontinence to solid, need to change a pad, and lifestyle changes.
A.M. Kaiser, ``The McGraw-Hill Manual of Colorectal Surgery,'' 743
(2009).
VA's proposed rating criteria provide descriptive criteria that
track the CCIS and objective means of determining functional
impairment, such as a degree of stool incontinence, a need to change a
pad, and lifestyle changes.
Specifically, VA proposes a 0-percent evaluation for a history of
impairment of sphincter control, but without current symptoms. VA
proposes a 10-percent evaluation when a veteran has incontinence or
retention that is fully responsive to a physician-prescribed bowel
program and requires either medication or special diet. Alternatively,
VA may assign a 10-percent evaluation with incontinence to solids and/
or liquids at least once every 6 months, and which requires wearing a
pad at least once every 6 months.
VA proposes a 30-percent evaluation when a veteran has incontinence
or retention that is fully responsive to a physician-prescribed bowel
program and requires digital stimulation, medication (beyond laxative
use), and special diet. Alternatively, a 30-percent evaluation is
proposed with incontinence to solids and/or liquids 2 or more times per
month, which requires changing a pad 2 or more times per month.
VA proposes a 60-percent evaluation when an individual has complete
or partial loss of sphincter control characterized by incontinence or
retention that is partially responsive to a physician-prescribed bowel
program, which requires either surgery or digital stimulation, as well
as prescribed medication (beyond laxative use) and special diet.
Alternatively, VA may assign a 60-percent evaluation for incontinence
to solids and/or liquids 2 or more times per week, which requires
changing of a pad 2 or more times per week.
VA proposes a 100-percent evaluation when a veteran has complete
loss of sphincter control characterized by incontinence or retention
that is not responsive to a physician-prescribed bowel program and that
requires either surgery or digital stimulation, with medication and
diet. Alternatively, VA may assign a 100-percent evaluation for
incontinence to solids and/or liquids 2 or more times per day, which
requires changing a pad 2 or more times per day.
Diagnostic Code 7333
The current rating criteria for DC 7333, stricture of the rectum
and anus, include: ``requiring colostomy'' for a 100-percent
evaluation; ``great reduction of lumen, or extensive leakage'' for a
50-percent evaluation; and ``moderate reduction of lumen, or moderate
constant leakage'' for a 30-percent evaluation. VA notes that this
proposed rulemaking includes a separate DC, DC 7329, which adequately
evaluates colostomy and ileostomy. As such, there is no longer a need
to include colostomy in the rating criteria for DC 7333. Instead, VA
proposes to add a Note (2), directing rating personnel to evaluate an
ostomy as DC 7329 (Intestine, large, resection of).
Further, VA proposes to remove from the rating criteria the
indefinite terms, such as ``great,'' ``extensive,'' and ``moderate,''
and instead replace them with objective criteria on the extent of
reduction of the lumen (or the opening of the anal canal). Brisinda,
G., et al., Surgical treatment of anal stenosis, World J Gastroenterol.
2009 Apr 28; 15(16): 1921-1928 (last visited Oct 06, 2021) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675080/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675080/</a>. Specifically, VA
proposes: A 10-percent evaluation for luminal narrowing with or without
straining during defecation, which is managed by dietary intervention;
a 30-percent evaluation for reduction of the lumen by less than 50
percent, with straining during defecation; a 60-percent evaluation for
the reduction of the lumen by at least 50 percent, with pain and
straining during defecation; and a 100-percent evaluation for the
inability to open the anus accompanied by the inability to expel solid
feces. Carrington, Emma V., at al., Advances in the evaluation of
anorectal function, Nat Rev Gastroenterol Hepatol. 2018 May; 15(5):
309-323., (last visited Oct. 06, 2021) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028941/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028941/</a>.
VA also advises in Note (1) that rating personnel may use this code
to evaluate such conditions as dyssynergic defecation (levator ani) and
anismus (functional constipation).
Diagnostic Code 7334
DC 7334, Prolapse of the rectum, currently provides the following
evaluations: 50 percent for ``severe (or complete), persistent'' rectal
prolapse; 30 percent for ``moderate, persistent or frequently
recurring'' rectal prolapse; and 10 percent for mild rectal prolapse
``with constant slight or occasional moderate leakage.'' These
criteria, employing such terms as ``mild,'' ``moderate,'' ``severe,''
or ``frequently recurring,'' are vague and subjective and may lead to
inconsistent decisions.
VA proposes to remove the subjective language and apply new rating
criteria based on precipitating factors, whether or not prolapse can be
reduced, along with whether or not surgical repair can be performed.
These elements are easily measured and represent accurate
[[Page 1534]]
proxies for occupational impairment. Seenivasagam, T., et al.,
Irreducible Rectal Prolapse: Emergency Surgical Management of Eight
Cases and A Review of the Literature Med J Malaysia Vol 66 No 2 June
2011 (last visited Oct. 06, 2021) <a href="http://www.e-mjm.org/2011/v66n2/Rectal_Prolapse.pdf">http://www.e-mjm.org/2011/v66n2/Rectal_Prolapse.pdf</a>.
Specifically, VA proposes a 10-percent evaluation for spontaneously
reducible prolapse that is not repairable. VA proposes a 30-percent
evaluation for manually reducible prolapse of the rectum that is not
repairable and occurs only after bowel movements, exertion, or
performing the Valsalva maneuver. VA proposes a 50-percent evaluation
for manually reducible prolapse that is not repairable and occurs at
times other than bowel movements, exertion, or while performing the
Valsalva maneuver. VA proposes to add a 100-percent evaluation for
persistent prolapse of the rectum that is irreducible, regardless of
whether it is repairable. A note would continue a 100-percent
evaluation for 2 months following any repair and provide that VA would
then evaluate the residual condition and apply 38 CFR 3.105(e) to any
change.
VA also proposes a second note instructing rating personnel to
provide a single evaluation under DC 7332 (Rectum and anus, impairment
of sphincter control) when sphincter control is the predominant
disability.
Diagnostic Code 7335
``Fistula-in-ano'' (DC 7335) is also known as ``anorectal
fistula.'' The criteria in this DC also apply to anorectal abscesses.
Therefore, VA proposes to add these names to the title to help rating
personnel correctly apply the criteria.
Currently, VA evaluates this condition analogously to DC 7332
(Rectum and anus, impairment of sphincter control). VA assigns
evaluations of 0, 10, 30, 60, or 100 percent based on loss of sphincter
control and involuntary bowel movements. However, the current rating
criteria for impairment of sphincter control does not consider the
primary disabling effects of fistulas, which are abscesses, pain, and
drainage. See J.L. Poggio, ``Fistula-in-Ano,'' Medscape Reference (Mar.
27, 2020), <a href="http://emedicine.medscape.com/article/190234-overview#showall">http://emedicine.medscape.com/article/190234-overview#showall</a> (last visited Oct. 06, 2021). Therefore, VA proposes
the following rating criteria to address the specific disabling effects
of fistula-in-ano: A 10-percent evaluation for a single fistula with
pain and discharge, but which is not accompanied by abscess; a 20-
percent evaluation for 2 or more simultaneous fistulas with some
drainage and pain, but not accompanied by abscess; a 40-percent
evaluation for 1 or 2 simultaneous fistulas accompanied by abscess,
drainage, and pain; and a 60-percent evaluation for more than 2
constant or near-constant fistulas with abscess, drainage, and pain,
which are refractory to medical and surgical treatment.
Diagnostic Code 7336
VA currently evaluates hemorrhoids (DC 7336) by assigning: A 20-
percent evaluation for ``persistent bleeding and with secondary anemia,
or for fissures;'' a 10-percent evaluation for hemorrhoids that are
``large or thrombotic, irreducible, with excessive redundant tissue,
evidencing frequent recurrences;'' and a 0-percent evaluation if they
are ``mild or moderate.''
Current medical understanding recognizes there are differences in
the expected presentations, exam findings, and treatment approaches
between internal hemorrhoids and external hemorrhoids. See Scott C.
Thornton,''Hemorrhoids'' Medscape Reference Sep. 24, 2019. <a href="https://emedicine.medscape.com/article/775407-overview">https://emedicine.medscape.com/article/775407-overview</a> (last visited Oct. 06,
2021). However, the current rating criteria do not differentiate
between internal and external hemorrhoids. As such, VA proposes to
include location in the rating criteria, as well as remove subjective
terms such as ``mild,'' ``moderate,'' ``excessive,'' and ``frequent,''
which may lead to inconsistent evaluations. VA would replace them with
more objective criteria that apply, in part, to any type of hemorrhoid
and, in part, only to either internal or external hemorrhoids.
VA therefore proposes to assign a 10-percent evaluation for
prolapsed internal hemorrhoids with 2 or less episodes per year of
thrombosis, or for external hemorrhoids with three or more episodes per
year of thrombosis. VA proposes a 20-percent evaluation for either of
the following: Internal or external hemorrhoids with persistent
bleeding and anemia, or continuously prolapsed internal hemorrhoids
with 3 or more episodes per year of thrombosis.
Diagnostic Code 7337
Pruritis ani (DC 7337) is an itching and a compelling need to
scratch the area around the anus. Therefore, for clarity, VA proposes
to add ``anal itching'' to the title of this code.
This condition is generally a symptom of another condition, such as
a skin disorder or hemorrhoids. Currently, VA directs rating personnel
to evaluate pruritis ani under the criteria provided for the underlying
condition. However, in many cases, this practice does not account for
the actual itching. Therefore, VA proposes to associate specific rating
criteria to better evaluate it, in addition to the underlying
condition.
Specifically, VA proposes to assign a 0-percent evaluation for anal
itching without bleeding or excoriation (tearing of the skin). VA
proposes to assign a maximum 10-percent evaluation if the condition is
associated with bleeding or excoriation.
Diagnostic Codes 7338, 7339 and 7340
Currently DC 7338 is titled as ``Hernia, inguinal,'' DC 7339 is
titled ``Hernia, ventral, postoperative,'' and DC 7340 is titled
``Hernia, femoral.'' For the reasons set forth below, VA proposes to
combine these three diagnostic codes into one diagnostic code, titled
``Hernia, including femoral, inguinal, umbilical, ventral, incisional,
and other (but not including hiatal).'' These different types of hernia
have similar functional impairments that arise from the weakness and/or
defects of the abdominal wall and associated pain. Even though the
location of the hernia may differ, this functional impairment results
in disabilities that can be quantified using similar elements,
permitting development of universally applicable evaluation criteria.
The elements for the proposed evaluation criteria are both objective
and measurable, which in turn ensures greater consistency of
adjudication process (inter-rater reliability).
A hernia is defined as a protrusion, bulge, or projection of an
organ or a part of an organ through the body wall that normally
contains it. There are a lot of different types of hernias to include
groin hernias (inguinal and femoral), umbilical, ventral, incisional,
hiatal, and other less common types such as epigastric, giant
abdominal, and spigelian. See WebMD Medical Reference, Medically
Reviewed by Neha Pathak, MD on September 21, 2020, What Are the Types
of Hernias? (last visited Oct. 06, 2021) <a href="https://www.webmd.com/digestive-disorders/types-of-hernias#1">https://www.webmd.com/digestive-disorders/types-of-hernias#1</a>. Most of the hernias, with
exception of hiatal hernias, share common features of functional
impairment due to abdominal wall defect, surgical approaches, and
treatment prognosis (functional outcomes). Hiatal hernias are different
from the other hernias because they involve a diaphragm, an internal
muscle that separates the chest from the abdominal cavity. With a
hiatal hernia there is no visible protrusion, but symptoms may include
heartburn, chest
[[Page 1535]]
pain, and a bad taste in the mouth, which are due to the upward flow of
stomach acid, air, or bile. Hiatal hernia is rated under DC 7346.
VA proposes to combine evaluations currently done under DCs 7338,
7339, and 7340 under new retitled DC 7338, ``Hernia, including femoral,
inguinal, umbilical, ventral, incisional, and other (but not including
hiatal).'' VA takes into consideration pain or discomfort somewhere on
the surface of the abdomen or in the groin area; however, a hernia can
also be painless and only appear as a bulge. VA proposes to base its
evaluation of disability due to new or recurrent hernia that is present
for 12 months or more on: (1) The size of the abdominal wall defect,
(2) the ability to surgically repair or reduce hernia (repairable
versus irreparable), and (3) the degree of postoperative functional
impairment.
VA proposes to evaluate the size of the abdominal wall defect using
the concept of ``loss of domain'' (LOD). LOD expresses the relationship
between the size of a hernia and abdominal volume (contents of the
abdominal cavity) where herniated contents of the abdominal cavity
permanently inhabit the hernia sac. See Parker, S. G., et al., What
Exactly is Meant by ``Loss of Domain'' for Ventral Hernia? Systematic
Review of Definitions. World J Surg. 2019; 43(2): 396-404. (last
visited Oct. 06, 2021) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329734/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329734/</a>. LOD is widely used to predict operative difficulty and
success, which in turn is indicative of any future functional
impairment and associated disability. See E. Tanaka ``A computerized
tomography scan method for calculating the hernia sac and abdominal
cavity volume in complex large incisional hernia with loss of domain.''
Hernia, vol. 14, Pg 64. 2010. (last visited Oct. 06, 2021) <a href="https://link.springer.com/article/10.1007%2Fs10029-009-0560-8">https://link.springer.com/article/10.1007%2Fs10029-009-0560-8</a>. Multiple sources
identify the ``cut-off'' threshold or percentage proportion above which
LOD becomes clinically significant (i.e. the point at which closing an
abdominal defect becomes very difficult and development of
complications is more likely), when a hernia's size is equal to 15 cm
or greater in one dimension. See Buenafe A. A., Lee-Ong, A., Lateral
release in the repair of large ventral hernia. Ann Laparosc Endosc Surg
2019; 4:24 (last visited Oct. 06, 2021) <a href="http://ales.amegroups.com/article/view/5038/html">http://ales.amegroups.com/article/view/5038/html</a>.
VA proposes to evaluate the degree of postoperative functional
impairment based on the Carolinas Comfort Scale (CCS). CCS is a
validated, disease-specific, quality of life (QOL) questionnaire
developed for patients undergoing hernia repair, which takes into
consideration an individual's ability to (1) bend over, (2) perform
activities of daily living (ADLs), (3) walk, and (4) climb stairs in
the presence or absence of postoperative pain. The presence of pain
during these activities increases the odds that a patient will not
return to work. See B. T. Heniford, ``Carolinas Comfort Scale as a
Measure of Hernia Repair Quality of Life,'' Annals of Surgery, vol
267(1), Pg. 175. January 2018. (last visited Oct. 06, 2021) <a href="https://insights.ovid.com/pubmed?pmid=27655239">https://insights.ovid.com/pubmed?pmid=27655239</a>. Furthermore, pain is the most
common symptom associated with hernia repair and can severely affect an
individual's functional status. See L. Chung, et. al., ``Pain and its
effects on physical activity and quality of life before operation in
patients undergoing elective inguinal and ventral hernia repair,'' Am J
Surg vol 208(3), Pg. 406-411. 2014. The CCS questionnaire proved to be
a reliable instrument for assessing quality of life and functional
impairment after hernia repair and has become a predominant outcome
measure in this discipline of surgery.
VA proposes a 100-percent evaluation for new or recurrent
irreparable hernia, which is present for 12 months or more, and with
both of the following features and symptoms that are present for 12
months or more: (1) Hernia size equal to 15 cm or greater in one
dimension; and (2) pain is present when performing at least three of
the following activities: Bending over, ADLs, walking, and climbing
stairs. In similar cases where pain is present when performing two of
the aforementioned activities, VA proposes a 60-percent disability
evaluation.
VA proposes a 30-percent evaluation for new or recurrent
irreparable hernia, which is present for 12 months or more, and with
both of the following features and symptoms that are present for 12
months or more: (1) Size is equal to 3 cm or greater but less than 15
cm in one dimension; and (2) pain is present when performing at least
two of the aformentioned activities. In similar cases where pain is
present when performing one of the aforementioned activities, VA
proposes a 20-percent disability evaluation.
VA proposes a 10-percent disability evaluation for new or recurrent
irreparable hernia, which is present for 12 months or more and with
hernia size smaller than 3 cm. VA proposes a 0-percent evaluation for
asymptomatic hernia, which is either present and repairable, or was
repaired.
Diagnostic Code 7344
VA proposes to add a note to DC 7344 clarifying that the conditions
evaluated under DC 7344 ``Benign neoplasms, exclusive of skin growths''
include lipoma, leiomyoma, colon polyps, and villous adenoma. VA would
not substantively change the instruction to evaluate the predominant
disability or the specific residuals after treatment under an
appropriate DC.
Diagnostic Code 7345
Currently, DC 7345 is titled ``Chronic liver disease without
cirrhosis (including Hepatitis B, chronic active hepatitis, autoimmune
hepatitis, hemochromatosis, drug-induced hepatitis, etc., but excluding
bile duct disorders and Hepatitis C).'' VA proposes to simplify this
title to ``Chronic liver disease without cirrhosis,'' which would be
consistent with current medical terminology.
The current rating criteria for DC 7345 assigns evaluations as
follows: A 100-percent evaluation for ``near-constant debilitating
symptoms (such as fatigue, malaise, nausea, vomiting, anorexia,
arthralgia, and right upper quadrant pain);'' a 60-percent evaluation
for ``daily fatigue, malaise, and anorexia with substantial weight loss
(or other indication of undernutrition), and hepatomegaly; or
incapacitating episodes (with symptoms such as fatigue, malaise,
nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain)
having a total duration of at least 6 weeks during the past 12-month
period, but not occurring constantly;'' a 40-percent evaluation for
``daily fatigue, malaise, and anorexia, with minor weight loss and
hepatomegaly, or incapacitating episodes (with symptoms such as
fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right
upper quadrant pain) having a total duration of at least 4 weeks, but
less than 6 weeks, during the past 12-month period;'' a 20-percent
evaluation for ``daily fatigue, malaise, and anorexia (without weight
loss or hepatomegaly) requiring dietary restriction or continuous
medication; or incapacitating episodes (with symptoms such as fatigue,
malaise, nausea, vomiting, anorexia, arthralgia, and right upper
quadrant pain) having a total duration of at least 2 weeks, but less
than 4 weeks, during the past 12-month period;'' a 10-percent
evaluation for ``intermittent fatigue, malaise, and anorexia, or
incapacitating episodes (with symptoms such as fatigue, malaise,
nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain)
having a total duration of at least
[[Page 1536]]
1 week, but less than 2 weeks, during the past 12-month period;'' and a
0-percent evaluation if the condition is not symptomatic.
Current rating criteria contain numerous references to subjective
factors, such as what constitutes an ``incapacitating episode'' and how
long it lasts, which may contribute to inconsistent adjudication
decisions. Similarly, the difference between ``minor'' versus
``substantial'' weight loss is ambiguous. Therefore, VA proposes to
include more objective factors, such as required medication and
laboratory evidence of liver damage. VA also intends to reduce the
number of disability levels from six (0, 10, 20, 40, 60, and 100) to
five (0, 20, 40, 60, and 100) because using more objective evidence-
based factors requires clearer distinctions between disability levels.
Veterans currently rated under DC 7345 would not see their disability
evaluations change solely because of these proposed revisions.
Additionally, VA takes into consideration significant advances in the
treatment and management of patients with viral hepatitis which
occurred during the last decade. Two major classes of antiviral
therapeutics have been adopted to treat the infection: Drugs that
directly interfere with virus replication (direct antiviral agents) and
drugs that modulate antiviral immune response (immunomodulatory drugs).
As a result, people experience better outcomes, fewer side effects and
shorter treatment times. For example, with the use of new antiviral
drugs, hepatitis C has become a curable disease in more that 95 percent
of the treated patients. See Roderburg, C. et al., Antiviral Therapy in
Patients with Viral Hepatitis and Hepatocellular Carcinoma: Indications
and Prognosis. Visc Med. 2016 Apr; 32(2): 121-126. (last visited Oct.
06, 2021) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926886/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926886/</a>.
VA recognizes that occupationally relevant symptoms, such as fever,
nausea, muscle aches and soreness, joint pain, and profound fatigue,
are common during hepatitis treatment. In some instances, headache,
insomnia, weight loss, or difficulties with memory or concentration,
can also occur. Bertoletti, A. and Le Bert, N., Immunotherapy for
Chronic Hepatitis B Virus Infection, Gut Liver. 2018 Sep; 12(5): 497-
507. (last visited Oct. 06, 2021) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143456/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143456/</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/29316747/">https://pubmed.ncbi.nlm.nih.gov/29316747/</a>.
Furthermore, treatment total effectiveness (``cure'') or sustained off-
treatment control (``functional cure'') of hepatitis infection is
determined by the inability to detect virus load for 6 months after
discontinuing therapy. VA proposes to maintain a 100-percent evaluation
during treatment with both parenteral (infusion) direct antiviral
agents (such as entecavir, lamivudine, tenofovir, telbivudine, and
other) and parenteral immunomodulatory drugs (such as interferon and
other). In a new Note (1), VA proposes to continue a 100-percent
evaluation for six months following discontinuance of treatment
(parenteral antiviral therapy and parenteral immunomodulatory drugs).
Thereafter, six months after discontinuance of parenteral antiviral
therapy and parenteral immunomodulatory drugs, VA proposes to determine
the appropriate disability rating by mandatory VA exam. Lastly, VA
proposes to apply the provisions of Sec. 3.105(e) to any change in
evaluation based upon that or any subsequent examination.
VA proposes a 60-percent evaluation for progressive chronic liver
disease that requires continuous medication and causes substantial
weight loss and at least two of the following symptoms: Daily fatigue,
malaise (feeling ill), anorexia (loss of appetite), hepatomegaly
(enlarged liver), pruritus (itch), and arthralgia (joint pain). VA
proposes a 40-percent evaluation for progressive chronic liver disease
that requires continuous medication and causes minor weight loss and at
least two of the following symptoms: Daily fatigue, malaise, anorexia,
hepatomegaly, pruritus, and arthralgia. VA proposes a 20-percent
evaluation for chronic liver disease accompanied by at least one of the
following symptoms: Intermittent fatigue, malaise, anorexia,
hepatomegaly, or pruritus. VA proposes to assign a 0-percent evaluation
for a history of liver disease without current symptoms.
VA proposes to retain existing Note (1) but re-designate it as Note
(4). VA recognizes that some individuals may not be able to receive
parenteral (infusion) antiviral or immunomodulatory therapy or a second
oral antiviral medication, despite physician recommendation, because
the use of such medications may be contraindicated in their specific
case. Therefore, VA proposes Note (2) that instructs rating personnel
to evaluate such cases under DC 7312 ``Cirrhosis of the liver.'' To
further assist VA adjudicators in delivering consistent rating
decisions, VA proposes an explanatory Note (3), which provides a list
of the disorders to be evaluated underusing this diagnostic code:
Hepatitis B, Primary Biliary Cirrhosis (PBC), Primary Sclerosing
Cholangitis (PSC), autoimmune liver disease, Wilson's disease, Alpha-1-
antitrypsin deficiency, hemochromatosis, drug-induced hepatitis, and
non-alcoholic steatohepatitis (NASH). The proposed Note (3) would also
contain the information discussed in current Note (3), namely, that
serologic testing must confirm Hepatitis B. Additionally, Note (3)
would clarify that while VA would evaluate Hepatitis C using the
criteria under DC 7345, rating personnel should code it under DC 7354
``Hepatitis C (or non-A, non-B hepatitis)'' so VA can track the claims
and decisions regarding Hepatitis C in the veterans' population.
Diagnostic Code 7346
Hiatal hernias occur when part of the stomach protrudes upwards
through the diaphragm (the muscle across the bottom of the rib cage
that helps control breathing). Symptoms are rare, but when present are
due to the upward flow of stomach acid, air, or bile. See ``Hiatal
Hernia,'' in ``A.D.A.M. Medical Encyclopedia,'' PubMed Health, U.S.
National Library of Medicine (April 24, 2017), <a href="https://medlineplus.gov/ency/article/001137.htm">https://medlineplus.gov/ency/article/001137.htm</a> (last accessed Nov. 6, 2018). Therefore, VA
proposes to retitle this DC as ``Hiatal hernia and paraesophageal
hernia'' to more accurately reflect the conditions VA is likely to
evaluate under this code.
VA currently assigns evaluations for hiatal hernias as follows: A
60-percent evaluation for symptoms of ``pain, vomiting, material weight
loss, and hematemesis or melena with moderate anemia, or other symptom
combinations productive of severe impairment of health;'' a 30-percent
evaluation for ``persistently recurrent epigastric distress with
dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm
or shoulder pain, productive of considerable impairment of health;''
and a 10-percent evaluation for 2 or more of the same symptoms as for
the 30 percent evaluation, but of less severity.
However, as discussed above, the medical community now recognizes
that impairment of the esophageal sphincter creates the majority of
symptoms. See Dakkak, supra. As such, VA proposes to delete the
existing rating criteria and instead instruct rating personnel to
evaluate this condition under DC 7203 (Esophagus, stricture of).
Diagnostic Code 7347
Currently, DC 7347 is titled ``Pancreatitis.'' Acute pancreatitis
can be a very serious, even life threatening, condition but most
individuals can expect complete recovery. Nevertheless, acute
pancreatitis can become chronic if
[[Page 1537]]
pancreatic tissue sustains irreversible damage and develops scarring
(fibrosis). Therefore, VA proposes to retitle this DC as
``Pancreatitis, chronic'' to more adequately reflect long-term
functional impairment of this condition.
The pancreas is the organ that produces enzymes necessary for
digestion. The inflammation from chronic pancreatitis disrupts the
production of necessary digestive enzymes, creating pancreatic
insufficiency. Etemad, B. and Whitcomb, D.C., Chronic pancreatitis:
Diagnosis, classification, and new genetic developments.
Gastroenterology 2001: Diagnostics & Therapeutics. Gastroenterology,
Volume 120, Issue 3, February 2001, Pages 682-707 (last visited Oct.
06, 2021) <a href="https://www.sciencedirect.com/science/article/pii/S001650850100796X?via%3Dihub">https://www.sciencedirect.com/science/article/pii/S001650850100796X?via%3Dihub</a>. Abdominal pain, with intermittent attacks
of severe pain, is the most prevalent symptom in individuals with
chronic pancreatitis. Other symptoms associated with chronic
pancreatitis include diarrhea and weight loss. Chronic pancreatitis is
a severe progressive debilitating illness that can worsen over time,
leading to permanent impairment. The clinical picture is complex,
involving multiple systems with occasional extreme debility and
confinement.
The current criteria for assigning evaluations are as follows: A
100-percent evaluation for frequently recurring disabling attacks of
abdominal pain with few pain-free intermissions and with steatorrhea
(excess fat in the stools), malabsorption, diarrhea, and severe
malnutrition; a 60-percent evaluation for frequent attacks of abdominal
pain, loss of normal body weight, and other findings showing continuous
pancreatic insufficiency between acute attacks; a 30-percent evaluation
for a moderately severe condition, with at least 4-7 typical attacks of
abdominal pain per year with good remission between attacks; and a 10-
percent evaluation for at least 1 recurring attack of typical severe
abdominal pain in the past year.
VA proposes new rating criteria that incorporate medical advances
in pain management, digestive enzyme replacement, and assisted
nutrition (tube enteral feeding). Additionally, the new rating criteria
accounts for complications resulting from pancreatic insufficiency, the
number of annual episodes, pain management, and hospitalizations.
VA proposes to remove the current 10-percent disability level,
which accounts for a single attack of abdominal pain in the past year,
which does not require any treatment or cause any long-term
complications. This level of functional impairment would have minimal
to no impact on earning capacity. VA proposes a 30-percent disability
evaluation for confirmed diagnosis of pancreatitis with at least one
episode per year of abdominal or mid-back pain that requires an ongoing
outpatient medical treatment for pain, digestive problems, or
management of related complications such as cyst or pseudocyst,
intestinal obstruction, or ascites. VA proposes a 60-percent evaluation
for three or more episodes of abdominal or mid-back pain per year, with
at least one episode per year requiring hospitalization for management
of complications related to abdominal pain or requiring enteral
feeding. VA proposes a 100-percent evaluation for daily episodes of
abdominal or mid-back pain requiring 3 or more hospitalizations per
year, as well as pain management by a physician, with maldigestion and
malabsorption requiring dietary restriction and pancreatic enzyme
supplementation.
In addition to the revised rating criteria, VA proposes to make
nonsubstantive changes to the existing Note (1) requiring laboratory
evidence or clinical studies confirming pancreatitis as the cause of
abdominal pain, as many other causes for such pain may exist. VA
proposes to delete the current Note (2). A newly proposed code, DC 7357
(Post-pancreatectomy syndrome), eliminates the need to instruct
personnel to rate total or partial pancreatectomy a minimum of 30
percent.
VA proposes replacing the current Note (2) with a note instructing
personnel to separately rate diabetes due to pancreatic insufficiency
under DC 7913 (Diabetes mellitus).
Diagnostic Code 7348
DC 7348, Vagotomy with pyloroplasty or gastroenterostomy, evaluates
complications that may occur following certain abdominal surgeries. At
one time, physicians commonly used these procedures to treat gastric
ulcer disease. See R.A. Hejazi et al., ``Postsurgical Gastroparesis,''
in ``Gastroparesis: Pathophysiology, Presentation, and Treatment,'' 194
(Henry P. Parkman and Richard W. McCallum eds. 2012). However,
medication now treats the majority of gastric ulcer disease. Today,
vagotomy most often follows lung transplant surgery. Id. Therefore, VA
proposes to remove the current reference to ``recurrent ulcer'' in the
criteria for a 20-percent evaluation, so it would then read simply
``with incomplete vagotomy.'' VA would not change the remainder of the
criteria.
Rating personnel are likely to continue to encounter veterans who
experienced permanent complications after surgeries to treat gastric
ulcers. Therefore, VA would retain the existing note on evaluating
recurrent gastric ulcer following complete vagotomy. However, to
maintain consistency with the overall amendments, the note would refer
rating personnel to the revised DC 7304 (Peptic ulcer disease), which
VA is proposing to expand to include all ulcer disease, rather than DC
7305 (Ulcer, duodenal), which VA is proposing to discontinue.
The current note under DC 7348 also instructs rating personnel to
evaluate dumping syndrome under DC 7308. As explained above in DC 7308,
VA believes that the most appropriate criteria for evaluating
postgastrectomy syndromes are in the new DC 7303, and proposes to
update the current note accordingly.
New Diagnostic Code 7350
A liver abscess is an infection of the liver that generally
produces symptoms of fever, chills, right upper quadrant pain, loss of
appetite, and a general feeling of poor health. Effective treatment
generally involves drainage of the abscess followed by antibiotics,
although prolonged antibiotic treatment may be used exclusively if the
individual is too ill to tolerate the drainage procedure. Ruben
Peralta, MD et al., ``Liver Abscess,'' Medscape Reference (Mar. 27,
2020) <a href="http://emedicine.medscape.com/article/188802">http://emedicine.medscape.com/article/188802</a> (last visited Oct.
06, 2021). Without treatment, liver abscess results in death. Id.
Liver abscess is relevant to veterans because it is associated with
travel to developing countries. M.P. Sharma et al., ``Amoebic Liver
Abscess,'' 4 J. of Indian Acad. of Clinical Med., 107 (Apr. 2003). VA
proposes a new DC for the three major types of liver abscess, including
pyogenic (infectious), amebic (due to Entamoeba hystolytica), and
fungal (related to Candida albicans and others). VA proposes a new note
under DC 7350 to inform rating personnel of the various types of
abscesses considered under the code.
VA proposes to assign a 100-percent evaluation for six months from
the onset of this condition (date of initial diagnosis) followed by a
mandatory VA examination to determine the appropriate evaluation based
on any residuals. VA would apply the provisions of Sec. 3.105(e) to
any reduction in evaluation. Furthermore, despite the availability of
anti-microbial agents,
[[Page 1538]]
modern antibiotics, and recent drainage techniques, liver abscesses can
still lead to severe debilitation and systemic manifestations of
anemia, infection, and liver function abnormalities that generally
resolve after a convalescence period lasting anywhere from 6 to 12
months. Therefore, VA proposes to rate the condition based on chronic
residuals under the appropriate body system.
Diagnostic Code 7351
VA proposes to maintain the existing criteria for liver transplant
(DC 7351), but intends to add a minimum 60-percent evaluation for those
awaiting retransplantation. Complications, such as side effects of
necessary medications, from an earlier transplant can contribute
significantly to functional impairment. Johnny C. Hong, MD, FACS et
al., ``Predictive Index for Long-Term Survival After Retransplantation
of the Liver in Adult Recipients: Analysis of a 26-Year Experience in a
Single Center'', 254 Annals of Surgery, 444 (Sept. 2011).
VA also proposes to amend the existing note to direct rating
personnel to evaluate the residuals of any recurrence of the underlying
liver disease under the appropriate DC, and combine that evaluation
with other post-transplant residuals under the appropriate body
system(s), subject to the provisions of Sec. 4.14 and 4.114.
New Diagnostic Code 7352
VA proposes to add a DC for pancreatic transplant. VA published its
existing rating schedule before surgeons first performed the procedure.
They now perform it with sufficient frequency to warrant inclusion.
Dixon B Kaufman MD, Ph.D., ``Pancreas Transplantation'', Medscape
Reference (Jul. 12, 2021), <a href="http://emedicine.medscape.com/article/429408">http://emedicine.medscape.com/article/429408</a>
(last visited Oct. 06, 2021).
VA proposes to assign a 100-percent evaluation beginning on the day
of hospital admission for transplant surgery. In addition, a note would
require a VA examination one year following hospital discharge to
determine the appropriate evaluation based on residuals, subject to the
provisions of Sec. 3.105(e). VA would assign a minimum 30-percent
evaluation for residuals of the necessary long-term immunosuppressive
medication. This practice conforms to the concept of horizontal equity
in other systems, such as a minimum 30 percent for cardiac
transplantation. In addition to the reference above by Kaufman, see
``Outcomes of Recipients With Pancreatic Transplant Alone Who Develop
End-Stage Renal Disease: S.K. Singh; S.J. Kim et. al. Am. Journal of
Transplantation 2016: 16(2):535-540.
Diagnostic Code 7354
The current rating criteria for Hepatitis C (or non-A, non-B
hepatitis) are identical to that for DC 7345 (Chronic liver disease
without cirrhosis). VA does not intend to apply different criteria for
Hepatitis C than for other types of hepatitis. For simplicity, VA
proposes to delete the existing rating criteria associated with this
code and replace it with a statement to evaluate Hepatitis C as DC 7345
(Chronic liver disease without cirrhosis). As noted above, VA would
retain the separate DC for Hepatitis C for purposes of tracking
information about claims and rating decisions.
New Diagnostic Code 7355
Celiac disease, also known as gluten-sensitive enteropathy, is a
chronic autoimmune disorder with gastrointestinal and extraintestinal
(systemic) manifestations. Individuals with celiac disease cannot
tolerate gluten (a protein commonly found in wheat, rye, and barley)
and experience symptoms that interfere with the digestion and
absorption of food nutrients. Gastrointestinal symptoms include chronic
diarrhea, abdominal bloating and pain, vomiting, constipation,
flatulence, and pale, foul-smelling, or fatty stool (steatorrhea). The
prognosis for patients with correctly diagnosed and treated celiac
disease is excellent. However, the prognosis for patients with celiac
disease who are not responding to gluten withdrawal and corticosteroid
treatment is generally poor. Furthermore, celiac disease with poor
response to the treatment has significant and often debilitating
maldigestive and malabsorption syndrome that affects multiple organ
systems. See ``Celiac Disease,'' in National Digestive Diseases
Information Clearinghouse, National Institute of Diabetes and Digestive
and Kidney Diseases, NIH Publication No. 08-4269 (Oct 2020), <a href="https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/definition-facts">https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/definition-facts</a> (last visited Oct. 06, 2021). The main systemic
(extraintestinal) manifestations of celiac disease are based on
malabsorption syndrome. Malabsorption refers to the impaired absorption
of nutrients and includes defects that occur both during the digestion
and absorption of food nutrients in the gastrointestinal tract.
Sometimes, absorption of a single nutrient component may be impaired
(such as lactose intolerance due to lactase deficiency). However, in
the case of systemic diseases such as celiac disease or Crohn's disease
(which affects the whole intestine), the absorption of almost all
nutrients is impaired. In severe cases, malabsorption causes
significant weight loss, anemia, hypocalcemia (low level of calcium in
the blood), osteopenia and osteoporosis (loss of calcium from bones),
Vitamin B deficiency, dermatitis herpetiformis (a skin rash), lymph
node enlargement, hormonal disorders (amenorrhea and infertility in
women and impotence and infertility in men), and a three-fold increased
risk for development of intestinal T cell-non Hodgkin's lymphoma, and
other gastrointestinal cancers such as adenocarcinoma of the small
intestine and pharynx. C. Catassi et al., ``Risk of Non-Hodgkin's
Lymphoma in Celiac Disease,'' 287(11) J. of the Am. Med. Asscn., 1413-
19 (2002).
In its new rating criteria, VA proposes to account for both
systemic (extraintestinal) and digestive manifestations of the disease.
VA proposes a 30-percent evaluation for malabsorption syndrome with
chronic diarrhea that is managed by medically-prescribed dietary
intervention such as a prescribed gluten-free diet, and without
nutritional deficiencies. VA proposes a 50-percent evaluation for
individuals with malabsorption syndrome that causes chronic diarrhea
managed by medically-prescribed dietary intervention, such as a
prescribed gluten-free diet, with present nutritional deficiencies due
to lactase and pancreatic insufficiency; and with systemic
manifestations including but not limited to, weakness and fatigue,
dermatitis, lymph node enlargement, hypocalcemia, low vitamin levels,
or atrophy of the inner intestinal lining shown on biopsy. VA proposes
an 80-percent evaluation for individuals with malabsorption syndrome
that causes weakness which interferes with ADLs. Additionally, these
individuals exhibit weight loss, which results in wasting and
nutritional deficiencies, and systemic manifestations of the disease
including, but not limited to, weakness and fatigue, dermatitis, lymph
node enlargement, hypocalcemia, low vitamin levels, anemia related to
malabsorption, and episodes of abdominal pain and diarrhea due to
lactase deficiency or pancreatic insufficiency. In addition to these
rating criteria, VA proposes to include a Note (1) directing that
appropriate serum antibody testing or endoscopy with biopsy
(intestinal) must confirm the diagnosis of celiac disease. For
evaluation of celiac disease with the
[[Page 1539]]
predominant disability of malabsorption (inability to absorb nutrients
from a diet), VA proposes to add a second note directing rating
personnel to select the greater evaluation between the rating criteria
under DC 7328 and the criteria under new DC 7355.
New Diagnostic Code 7356
VA proposes a new code to evaluate and track a group of
gastrointestinal conditions characterized by chronic or recurrent
symptoms that are unexplained by any structural, endoscopic,
laboratory, or other objective signs of injury or disease. In the
American veterans population, these gastrointestinal conditions are
often associated with service in the Southwest Asia theater of
operations during the Persian Gulf War. Gastrointestinal dysmotility
syndrome is a broad term which is used to cover a spectrum of
gastrointestinal disorders with abnormal intestinal contractions
(spasms or intestinal paralysis). Coordinated movements of the
esophagus, stomach, and intestines are required to digest and move
intestinal contents along the digestive tract. See Paine. P., et al.,
Review article: The assessment and management of chronic severe
gastrointestinal dysmotility in adults. (last visited Oct. 06, 2021)
<a href="https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12496">https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12496</a>. These
digestive disorders occur in the absence of tissue damage in the
gastrointestinal tract and are functional, rather than structural, in
nature. At the request of Congress, the Institute of Medicine (IOM)
extensively studied conditions resulting from deployment during the
1991 Persian Gulf War. Institute of Medicine (US) Committee on Gulf War
and Health: Health Effects of Serving in the Gulf War, Update 2009.
Washington (DC): National Academies Press (US); 2010. (last visited
Oct. 06, 2021) <a href="https://www.ncbi.nlm.nih.gov/books/NBK220118/">https://www.ncbi.nlm.nih.gov/books/NBK220118/</a>. In its
reports, the IOM determined that Gulf War service causes, ``post-
traumatic stress disorder (PTSD) and that service is associated with
multisymptom illness; gastrointestinal disorders such as irritable
bowel syndrome; alcohol and other substance abuse; and anxiety
disorders and other psychiatric disorders.'' The IOM report identified
and validated functional digestive disorders as disabling and provided
the basis for VA to presume their relationship to military service.
``Presumptive Service Connection for Diseases Associated with Service
in the Southwest Asia Theater of Operations in the Persian Gulf War:
Functional Gastrointestinal Disorders,'' 76 FR 41696 (July 15, 2011).
Therefore, VA proposes a new diagnostic code 7356, Gastrointestinal
dysmotility syndrome, to evaluate a group of these functional digestive
disorders.
VA proposes evaluation of gastrointestinal motility disorders based
on the most common presentations, including but not limited to,
abdominal pain, bloating, feeling of epigastric fullness, dyspepsia,
nausea and vomiting, regurgitation, constipation, diarrhea, episodes of
intestinal obstruction and pseudo-obstruction (absence of mechanical
obstruction), and poor gastric emptying. Additionally, VA would take
into consideration the presence of nutritional compromise (i.e.,
requirement for assisted parental nutrition (tube feeding) and/or total
parental nutrition (TPN)) and response to treatment (i.e., requirement
for ambulatory and/or inpatient care). See Mia L Manabat ``Intestinal
Motility Disorders,'' Medscape Reference, (Sep. 16, 2020). <a href="https://emedicine.medscape.com/article/179937-overview">https://emedicine.medscape.com/article/179937-overview</a> (last visited Oct. 06,
2021). This evaluation is consistent with other disability ratings
which require similar levels of nutritional support such as TPN or tube
feeding.
Specifically, VA proposes a 10-percent evaluation for intermittent
abdominal pain with epigastric fullness associated with bloating, and
without evidence of a structural gastrointestinal disease. VA proposes
a 30-percent evaluation for symptoms of pseudo-obstruction (CIPO) as
well as symptoms of intestinal motility disorder such as abdominal
pain, bloating, feeling of epigastric fullness, dyspepsia, nausea and
vomiting, regurgitation, constipation, and diarrhea, managed by
ambulatory care and requiring prescribed dietary management or
manipulation. VA proposes a 50-percent evaluation where intermittent
tube feeding is required and the individual has recurrent emergency
treatment for episodes of intestinal obstruction or regurgitation due
to poor gastric emptying, abdominal pain, recurrent nausea, or
vomiting. VA proposes an 80-percent evaluation for complete dependence
on total parenteral nutrition (TPN) or continuous tube feeding for
nutritional support. VA proposes to add a note that this DC is
applicable to illnesses associated with 38 CFR 3.317(a)(2)(i)(B)(3)
(medically unexplained chronic multisymptom illness involving
functional gastrointestinal disorders in Persian Gulf veterans), other
than those which can be evaluated under DC 7319.
New Diagnostic Code 7357
As noted above, VA proposes to add a DC to Sec. 4.114 to evaluate
veterans that have post-pancreatectomy syndromes, which follow
therapeutic pancreatectomies either to remove cancers or to treat
complications of chronic pancreatitis. The post-pancreatectomy
condition resulting from the removal of the pancreas can vary in
degrees of severity, but is generally less severe than prior to
surgery. See Lewis Rashid and Vic Velanovich, ``Symptomatic change and
gastrointestinal quality of life after pancreatectomy,'' 14(1) HPB 9,
11 (Jan. 2012), <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252985/pdf/hpb0014-0009.pdf">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252985/pdf/hpb0014-0009.pdf</a> (last visited Oct. 06, 2021). See also D.G. Heidt
et al., ``Total Pancreatectomy: Indications, Technique, Sequelae,'' 11
J. of Gastrointestinal Surgery 209 (2007).
VA proposes to rate this condition based on the highest evaluation
under either DC 7347 (Pancreatitis, chronic), DC 7303 (Chronic
complications of upper gastrointestinal surgery, including operations
performed on the esophagus, stomach, pancreas, and small intestine,
including bariatric surgery), or residuals, such as malabsorption (DC
7328), diarrhea (DC 7319 or 7326), diabetes (DC 7913), or chronic
pancreatitis pain (DC 7347). Consistent with the current rating
schedule, VA would assign a minimum rating of 30 percent if no higher
evaluation is warranted under this or other DCs.
Executive Orders 12866 and 13563
Executive Orders 12866 and 13563 direct agencies to assess the
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, and other advantages; distributive impacts;
and equity). Executive Order 13563 (Improving Regulation and Regulatory
Review) emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
The Office of Information and Regulatory Affairs has determined that
this rule is an economically significant regulatory action under
Executive Order 12866. The Regulatory Impact Analysis associated with
this rulemaking can be found as a supporting document at
<a href="http://www.regulations.gov">www.regulations.gov</a>.
[[Page 1540]]
Regulatory Flexibility Act
The Secretary hereby certifies that this rule will not have a
significant economic impact on a substantial number of small entities
as they are defined in the Regulatory Flexibility Act (5 U.S.C. 601-
612). The certification is based on the fact that small entities or
businesses are not affected by revisions to the VASRD. Therefore,
pursuant to 5 U.S.C. 605(b), the initial and final regulatory
flexibility analysis requirements of 5 U.S.C. 603 and 604 do not apply.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in the expenditure by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any given year. This proposed rule would have no such
effect on State, local, and tribal governments, or on the private
sector.
Paperwork Reduction Act
This document contains no provisions constituting a collection of
information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).
Catalog of Federal Domestic Assistance Numbers and Titles
The Catalog of Federal Domestic Assistance program numbers and
titles for this rule are 64.104, Pension for Non-Service-Connected
Disability for Veterans; 64.109, Veterans Compensation for Service-
Connected Disability; and 64.110, Veterans Dependency and Indemnity
Compensation for Service-Connected Death.
List of Subjects in 38 CFR Part 4
Disability benefits, Pensions, Veterans.
Signing Authority
Denis McDonough, Secretary of Veterans Affairs, approved this
document on July 6, 2021, and authorized the undersigned to sign and
submit the document to the Office of the Federal Register for
publication electronically as an official document of the Department of
Veterans Affairs.
Luvenia Potts,
Regulation Development Coordinator Office of Regulation Policy &
Management, Office of General Counsel, Department of Veterans Affairs.
For the reasons set out in the preamble, VA proposes to amend 38
CFR part 4 as set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
Subpart B--Disability Ratings
0
1. The authority citation for part 4, subpart B, continues to read as
follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
Sec. 4.110 [Removed and Reserved]
0
2. Remove and reserve Sec. 4.110.
Sec. 4.111 [Removed and Reserved]
0
3. Remove and reserve Sec. 4.111.
0
4. Revise Sec. 4.112 to read as follows:
Sec. 4.112. Weight loss and nutrition.
The following terms apply when evaluating conditions in 38 CFR
4.114:
(a) Weight loss. ``Substantial weight loss'' means involuntary loss
greater than 20 percent of an individual's baseline weight sustained
for three months with diminished quality of self-care or work tasks.
The term ``minor weight loss'' means involuntary weight loss between 10
and 20 percent of an individual's baseline weight sustained for three
months with gastrointestinal-related symptoms, involving diminished
quality of self-care or work tasks, or decreased food intake. The term
``inability to gain weight'' means substantial weight loss with the
inability to regain it despite following appropriate therapy.
(b) Baseline weight: ``Baseline weight'' means the clinically
documented average weight for the two-year period preceding the onset
of illness or, if relevant, the weight recorded at the veteran's most
recent discharge physical. If neither of these weights is available or
currently relevant, then use ideal body weight as determined by either
the Hamwi formula or Body Mass Index tables, whichever is most
favorable to the veteran.
(c) Undernutrition: ``Undernutrition'' means a deficiency resulting
from insufficient intake of one or multiple essential nutrients, or the
inability of the body to absorb, utilize, or retain such nutrients.
Undernutrition is characterized by failure of the body to maintain
normal organ functions and healthy tissues. Signs and symptoms may
include: Loss of subcutaneous tissue, edema, peripheral neuropathy,
muscle wasting, weakness, abdominal distention, ascites, and Body Mass
Index below normal range.
(d) Nutritional support: The following describe various nutritional
support methods used to treat certain digestive conditions.
(1) Total parenteral nutrition or hyperalimentation is a special
liquid mixture given into the blood through an intravenous catheter.
The mixture contains proteins, carbohydrates (sugars), fats, vitamins,
and minerals. Total parenteral nutrition bypasses the normal digestion
in the stomach and bowel.
(2) Assisted enteral nutrition requires a special liquid mixture
(containing proteins, carbohydrates (sugar), fats, vitamins and
minerals) to be delivered into the stomach or bowel through a flexible
feeding tube. Percutaneous endoscopic gastrostomy is a type of assisted
enteral nutrition in which a flexible feeding tube is inserted through
the abdominal wall and into the stomach. Nasogastric or nasoenteral
feeding tube is a type of assisted parental nutrition in which a
flexible feeding tube is inserted through the nose into the stomach or
bowel.
0
5. Amend Sec. 4.114 by:
0
a. Revising the introductory text;
0
b. Revising the entries for diagnostic codes 7200 through 7205;
0
c. Adding in numerical order diagnostic codes 7206 and 7207;
0
d. Revising the entry for diagnostic code 7301;
0
e. Adding in numerical order an entry for diagnostic code 7303;
0
f. Revising the entry for diagnostic code 7304;
0
g. Removing diagnostic codes 7305 and 7306;
0
h. Revising the entries for diagnostic codes 7307 through 7310, 7312,
7314, and 7315;
0
i. Removing diagnostic code 7316;
0
j. Revising the entries for diagnostic codes 7317 through 7319;
0
k. Removing diagnostic codes 7321 and 7322;
0
l. Revising the entry for diagnostic code 7323;
0
m. Removing diagnostic code 7324;
0
n. Revising the entries for diagnostic codes 7325 through 7330, and
7332 through 7338;
0
o. Removing diagnostic codes 7339 and 7340;
0
p. Revising diagnostic codes 7344 through 7348;
0
q. Adding in numerical order an entry for diagnostic code 7350;
0
r. Revising the entry for diagnostic code 7351;
[[Page 1541]]
0
s. Adding in numerical order an entry for diagnostic code 7352;
0
t. Revising the entry for diagnostic code 7354;
0
u. Adding in numerical order entries for diagnostic codes 7355 through
7357.
The revisions and additions read as follows:
Sec. 4.114 Schedule of ratings--digestive system.
Do not combine ratings under diagnostic codes 7301 to 7329
inclusive, 7331, 7342, 7345 to 7350 inclusive, 7352, and 7355 to 7357
inclusive, with each other. Instead, assign a single evaluation under
the diagnostic code that reflects the predominant disability picture,
elevating it to the next higher evaluation as warranted by the severity
of the overall disability.
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
7200 Soft tissue injury of the mouth, other than tongue
or lips:
Rate as for disfigurement (diagnostic codes 7800 and
7804) and impairment of mastication.
7201 Lips, injuries of:
Rate as disfigurement (diagnostic codes 7800 and
7804).
7202 Tongue, loss of whole or part:
Absent oral nutritional intake...................... 100
Intact oral nutritional intake with permanently 60
impaired swallowing function that requires
prescribed dietary modification....................
Intact oral nutritional intake with permanently 30
impaired swallowing function without prescribed
dietary modification...............................
Note (1): Review for entitlement to special monthly
compensation under Sec. 3.350 of this chapter.
Note (2): Dietary modifications due to this
condition must be prescribed by a medical provider.
7203 Esophagus, stricture of:
Documented history of recurrent or refractory 80
esophageal stricture(s) causing dysphagia with at
least one of the symptoms present: (1) Aspiration,
(2) undernutrition, and/or (3) substantial weight
loss as defined by Sec. 4.112(a) and treatment
with either surgical correction or percutaneous
esophago-gastrointestinal tube (PEG tube)..........
Documented history of recurrent or refractory 50
esophageal stricture(s) causing dysphagia which
requires at least one of the following (1) dilation
3 or more times per year, (2) dilation using
steroids at least one time per year, or (3)
esophageal stent placement.........................
Documented history of recurrent or refractory 30
esophageal stricture(s) causing dysphagia which
requires dilatation no more than 2 times per year..
Documented history of esophageal stricture(s) that 10
requires daily medications to control dysphagia
otherwise asymptomatic.............................
Documented history without daily symptoms or 0
requirement for daily medications..................
Note (1): Findings must be documented by barium
swallow, computerized tomography, or
esophagogastroduodenoscopy.........................
Note (2): Non-gastrointestinal complications of
procedures should be rated under the appropriate
system.............................................
Note (3): This diagnostic code applies, but is not
limited to, esophagitis, mechanical or chemical;
Mallory Weiss syndrome (bleeding at junction of
esophagus and stomach due to tears) due to caustic
ingestion of alkali or acid; drug-induced or
infectious esophagitis due to Candida, virus, or
other organism; idiopathic eosinophilic, or
lymphocytic esophagitis; esophagitis due to
radiation therapy; esophagitis due to peptic
stricture; and any esophageal condition that
requires treatment with sclerotherapy..............
Note (4): Recurrent esophageal stricture is defined
as the inability to maintain target esophageal
diameter beyond 4 weeks after the target diameter
has been achieved..................................
Note (5): Refractory esophageal stricture is defined
as the inability to achieve target esophageal
diameter despite receiving no fewer than 5 dilation
sessions performed at 2-week intervals.............
7204 Esophageal motility disorder:
Rate as esophagus, stricture of (DC 7203).
Note: This diagnostic code applies, but is not
limited to, achalasia (cardiospasm), diffuse
esophageal spasm (DES), corkscrew esophagus,
nutcracker esophagus, and other motor disorders of
the esophagus; esophageal rings (including Schatzki
rings), mucosal webs or folds, and impairment of
the esophagus caused by systemic conditions such as
myasthenia gravis, scleroderma, and other
neurologic conditions..............................
7205 Esophagus, diverticulum of, acquired:
Rate as esophagus, stricture of (DC 7203).
Note: This diagnostic code, applies, but is not
limited to, pharyngo- esophageal (Zenker's)
diverticulum, mid-esophageal diverticulum, and
epiphrenic (distal esophagus) diverticulum.
7206 Gastroesophageal reflux disease:
Rate as esophagus, stricture of (DC 7203)...........
7207 Barrett's esophagus:
With esophageal stricture: Rate as esophagus,
stricture of (DC 7203).............................
Without esophageal stricture:
Documented by pathologic diagnosis with high- 30
grade dysplasia................................
Documented by pathologic diagnosis with low- 10
grade dysplasia................................
Note (1): If malignancy develops, rate as malignant
neoplasms of the digestive system, exclusive of
skin growths (DC 7343).
Note (2): If the condition is resolved via surgery,
radiofrequency ablation, or other treatment, rate
residuals as esophagus, stricture of (DC 7203).....
7301 Peritoneum, adhesions of, due to surgery, trauma,
disease, or infection:
Persistent partial bowel obstruction that is either 80
inoperable and refractory to treatment, or requires
total parenteral nutrition (TPN) for obstructive
symptoms...........................................
Symptomatic peritoneal adhesions, persisting or 50
recurring after surgery, trauma, inflammatory
disease process such as chronic cholecystitis or
Crohn's disease, or infection, as determined by a
healthcare provider; and clinical evidence of
recurrent obstruction requiring hospitalization at
least once a year; and medically-directed dietary
modification other than total parenteral nutrition;
and at least one of the following: (1) Abdominal
pain, (2) nausea, (3) vomiting, (4) colic, (5)
constipation, or (6) diarrhea......................
Symptomatic peritoneal adhesions, persisting or 30
recurring after surgery, trauma, inflammatory
disease process such as chronic cholecystitis or
Crohn's disease, or infection, as determined by a
healthcare provider; and medically-directed dietary
modification other than total parenteral nutrition;
and at least one of the following: (1) Abdominal
pain, (2) nausea, (3) vomiting, (4) colic, (5)
constipation, or (6) diarrhea......................
[[Page 1542]]
Symptomatic peritoneal adhesions, persisting or 10
recurring after surgery, trauma, inflammatory
disease process such as chronic cholecystitis or
Crohn's disease, or infection, as determined by a
healthcare provider, and at least one of the
following: (1) Abdominal pain, (2) nausea, (3)
vomiting, (4) colic, (5) constipation, or (6)
diarrhea...........................................
History of peritoneal adhesions, currently 0
asymptomatic.......................................
7303 Chronic complications of upper gastrointestinal
surgery:
Requiring continuous total parenteral nutrition 80
(TPN) or tube feeding for a period longer than 30
consecutive days in the last six months............
Any one of the following symptoms with or without 50
pain: (1) Daily vomiting not controlled by oral
dietary modification or medication; (2) six or more
watery bowel movements per day every day, or
explosive bowel movements that are difficult to
predict or control; (3) post-prandial (meal-
induced) light-headedness (syncope) with sweating
and the need for medications to specifically treat
complications of upper gastrointestinal surgery
such as dumping syndrome or delayed gastric
emptying...........................................
With two or more of the following symptoms: (1) 30
Vomiting two or more times per week or vomiting not
controlled by medical treatment; (2) discomfort or
pain within an hour of eating and requiring ongoing
oral dietary modification; (3) three to five watery
bowel movements per day every day..................
With either nausea or vomiting managed by ongoing 10
medical treatment..................................
Post-operative status, asymptomatic................. 0
Note (1): For resection of small intestine, use DC
7328.
Note (2): If pancreatic surgery results in a vitamin
or mineral deficiency (e.g., B12, iron, calcium, or
fat-soluble vitamins), evaluate under the
appropriate vitamin/mineral deficiency code and
assign the higher rating. For example, evaluate
Vitamin A, B, C or D deficiencies under DC 6313;
ocular manifestations of vitamin deficiencies, such
as night blindness, under DC 6313; keratitis or
keratomalacia due to Vitamin A deficiency under DC
6001; Vitamin E deficiency under neuropathy; and
Vitamin K deficiency under prolonged clotting
(e.g., DC 7705)....................................
Note (3): This diagnostic code includes operations
performed on the esophagus, stomach, pancreas, and
small intestine, including bariatric surgery.......
7304 Peptic ulcer disease:
Post-operative for perforation or hemorrhage, for 100
three months.......................................
Continuous abdominal pain with intermittent 60
vomiting, recurrent hematemesis (vomiting blood) or
melena (tarry stools); and manifestations of anemia
which require hospitalization at least once in the
past 12 months.....................................
Episodes of abdominal pain, nausea, or vomiting, 40
that: Last for at least three consecutive days in
duration; occur four or more times in the past 12
months; and are managed by daily prescribed
medication.........................................
Episodes of abdominal pain, nausea, or vomiting, 20
that: Last for at least three consecutive days in
duration; occur three times or less in the past 12
months; and are managed by daily prescribed
medication.........................................
History of peptic ulcer disease documented by 0
endoscopy or X-ray.................................
Note: After three months at the 100-percent
evaluation, rate on residuals as determined by
mandatory VA medical examination.
7307 Gastritis, chronic:
Rate as peptic ulcer disease (DC 7304).
Note: This diagnostic code includes Helicobacter
pylori infection, drug-induced gastritis, Zollinger-
Ellison syndrome, and portal-hypertensive
gastropathy with varix-related complications.......
7308 Postgastrectomy syndrome:
Rate residuals as chronic complications of upper
gastrointestinal surgery (DC 7303).
7309 Stomach, stenosis of:
Rate as chronic complications of upper
gastrointestinal surgery (DC 7303) or peptic ulcer
disease (DC 7304), depending on the predominant
disability.
7310 Stomach, injury of, residuals:
Pre-operative: Rate as adhesions of peritoneum due
to surgery, trauma, disease, or infection (DC
7301). No adhesions are necessary when evaluating
under DC 7301.
Post-operative: Rate as chronic complications of
upper gastrointestinal surgery (DC 7303).
* * * * * *
7312 Cirrhosis of the liver:
Liver disease with Model for End-Stage Liver Disease 100
score greater than or equal to 15; or with
continuous daily debilitating symptoms, generalized
weakness and at least one of the following: (1)
Ascites (fluid in the abdomen), or (2) a history of
spontaneous bacterial peritonitis, or (3)
encephalopathy, or (4) variceal hemorrhage, or (5)
coagulopathy, or (6) portal gastropathy, or (7)
hepatopulmonary or hepatorenal syndrome............
Liver disease with Model for End-Stage Liver Disease 60
score greater than 11 but less than 15; or with
daily fatigue and at least one episode in the last
year of either (1) variceal hemorrhage, or (2)
portal gastropathy or hepatic encephalopathy.......
Liver disease with Model for End-Stage Liver Disease 30
score of 10 or 11; or with signs of portal
hypertension such as splenomegaly or ascites (fluid
in the abdomen) and either weakness, anorexia,
abdominal pain, or malaise.........................
Liver disease with Model for End-Stage Liver Disease 10
score greater than 6 but less than 10; or with
evidence of either anorexia, weakness, abdominal
pain or malaise....................................
Asymptomatic, but with a history of liver disease... 0
Note (1): Rate hepatocellular carcinoma occurring
with cirrhosis under DC 7343 (Malignant neoplasms
of the digestive system, exclusive of skin growths)
in lieu of DC 7312.................................
Note (2): Biochemical studies, imaging studies, or
biopsy must confirm liver dysfunction (including
hyponatremia, thrombocytopenia, and/or
coagulopathy)......................................
Note (3): Rate condition based on symptomatology
where the evidence does not contain a Model for End-
Stage Liver Disease score..........................
7314 Chronic biliary tract disease:
With three or more clinically documented attacks of 30
right upper quadrant pain with nausea and vomiting
during the past 12 months; or requiring dilatation
of biliary tract strictures at least once during
the past 12 months.................................
With one or two clinically documented attacks of 10
right upper quadrant pain with nausea and vomiting
in the past 12 months..............................
[[Page 1543]]
Asymptomatic, without history of a clinically 0
documented attack of right upper quadrant pain with
nausea and vomiting in the past 12 months..........
Note: This diagnostic code includes cholangitis,
biliary strictures, Sphincter of Oddi dysfunction,
bile duct injury, and choledochal cyst. Rate
primary sclerosing cholangitis under chronic liver
disease without cirrhosis (DC 7345)................
7315 Cholelithiasis, chronic:
Rate as chronic biliary tract disease (DC 7314).
7317 Gallbladder, injury of:
Rate as adhesions of the peritoneum due to surgery,
trauma, disease, or infection (DC 7301); or chronic
gallbladder and biliary tract disease (DC 7314), or
cholecystectomy (gallbladder removal),
complications of (such as strictures and biliary
leaks) (DC 7318), depending on the predominant
disability.........................................
Note: No adhesions are necessary when evaluating
gallbladder injuries under DC 7301.
7318 Cholecystectomy (gallbladder removal),
complications of (such as strictures and biliary
leaks):
With recurrent abdominal pain (post-prandial or 30
nocturnal) ; and chronic diarrhea characterized by
three or more watery bowel movements per day.......
With intermittent abdominal pain; and diarrhea 10
characterized by one to two watery bowel movements
per day............................................
Asymptomatic........................................ 0
7319 Irritable bowel syndrome (IBS):
Abdominal pain related to defecation at least one 30
day per week during the previous three months; and
two or more of the following: (1) Change in stool
frequency, (2) change in stool form , (3) altered
stool passage (straining and/or urgency), (4)
mucorrhea, (5) abdominal bloating, or (6)
subjective distension..............................
Abdominal pain related to defecation for at least 20
three days per month during the previous three
months; and two or more of the following: (1)
Change in stool frequency, (2) change in stool
form, (3) altered stool passage (straining and/or
urgency), (4) mucorrhea, (5) abdominal bloating, or
(6) subjective distension..........................
Abdominal pain related to defecation at least once 10
during the previous three months; and two or more
of the following: (1) Change in stool frequency,
(2) change in stool form, (3) altered stool passage
(straining and/or urgency), (4) mucorrhea, (5)
abdominal bloating, or (6) subjective distention...
Note (1): This diagnostic code may include
functional digestive disorders (see 38 CFR Sec.
3.317), such as dyspepsia, functional bloating and
constipation, and diarrhea. Evaluate other symptoms
of a functional digestive disorder not encompassed
by this diagnostic code under the appropriate
diagnostic code, to include gastrointestinal
dysmotility syndrome (DC 7356), following the
general principles of Sec. Sec. 4.14 and 4.114..
7323 Colitis, ulcerative:
Rate as Crohn's disease or undifferentiated form of
inflammatory bowel disease (DC 7326).
7325 Enteritis, chronic:
Rate as Irritable Bowel Syndrome (DC 7319) or
Crohn's disease or undifferentiated form of
inflammatory bowel disease (DC 7326), depending on
the predominant disability.........................
7326 Crohn's disease or undifferentiated form of
inflammatory bowel disease:
Severe inflammatory bowel disease that is 100
unresponsive to treatment; and requires
hospitalization at least once per year; and results
in either an inability to work or is characterized
by recurrent abdominal pain associated with at
least two of the following: (1) Six or more
episodes per day of diarrhea, (2) six or more
episodes per day of rectal bleeding, (3) recurrent
episodes of rectal incontinence, or (4) recurrent
abdominal distention...............................
Moderate inflammatory bowel disease that is managed 60
on an outpatient basis with immunosuppressants or
other biologic agents; and is characterized by
recurrent abdominal pain, four to five daily
episodes of diarrhea; and intermittent signs of
toxicity such as fever, tachycardia, or anemia.....
Mild to moderate inflammatory bowel disease that is 30
managed with oral and topical agents (other than
immunosuppressants or other biologic agents); and
is characterized by recurrent abdominal pain with
three or less daily episodes of diarrhea and
minimal signs of toxicity such as fever,
tachycardia, or anemia.............................
Minimal to mild symptomatic inflammatory bowel 10
disease that is managed with oral or topical agents
(other than immunosuppressants or other biologic
agents); and is characterized by recurrent
abdominal pain with three or less daily episodes of
diarrhea and no signs of systemic toxicity.........
Note (1): Following colectomy/colostomy with
persistent or recurrent symptoms, rate either under
DC 7326 or DC 7329 (Intestine, large, resection
of), whichever provides the highest rating.........
Note (2): VA requires diagnoses under DC 7326 to be
confirmed by endoscopy or radiologic studies.
Note (3): Inflammation may involve small bowel
(ileitis), large bowel (colitis), or inflammation
of any component of the gastrointestinal tract from
the mouth to the anus..............................
7327 Diverticulitis and diverticulosis:
Diverticular disease requiring hospitalization for 30
abdominal distress, fever, and leukocytosis
(elevated white blood cells) one or more times in
the past 12 months; and with at least one of the
following complications: (1) Hemorrhage, (2)
obstruction, (3) abscess, (4) peritonitis, or (5)
perforation........................................
Diverticular disease requiring hospitalization for 20
abdominal distress, fever, and leukocytosis
(elevated white blood cells) one or more times in
the past 12 months; and without associated (1)
hemorrhage, (2) obstruction, (3) abscess, (4)
peritonitis, or (5) perforation....................
Asymptomatic; or a symptomatic diverticulitis or 0
diverticulosis that is managed by diet and
medication.........................................
Note: For colectomy or colostomy, use DC 7327 or DC
7329 (Intestine, large, resection of), whichever
results in a higher evaluation.
7328 Intestine, small, resection of:
Status post intestinal resection with undernutrition 80
and anemia; and requiring total parenteral
nutrition (TPN)....................................
Status post intestinal resection with undernutrition 60
and anemia; and requiring prescribed oral dietary
supplementation, continuous medication and
intermittent total parental nutrition (TPN)........
Status post intestinal resection with four or more 40
episodes of diarrhea per day resulting in
undernutrition and anemia; and requiring prescribed
oral dietary supplementation and continuous
medication.........................................
Status post intestinal resection with four or more 20
episodes of diarrhea per day.......................
Status post intestinal resection, asymptomatic...... 0
[[Page 1544]]
Note: This diagnostic code includes short bowel
syndrome, mesenteric ischemic thrombosis, and post-
bariatric surgery complications. Where short bowel
syndrome results in high-output syndrome, to
include high-output stoma, consider assigning a
higher evaluation under DC 7329 (Intestine, large,
resection of)......................................
7329 Intestine, large, resection of:
Total colectomy with formation of ileostomy, high- 100
output syndrome, and more than two episodes of
dehydration requiring intravenous hydration in the
past 12 months.....................................
Total colectomy without high-output syndrome........ 60
Partial colectomy with permanent colostomy.......... 40
Partial colectomy with reanastomosis (reconnection 20
of the intestinal tube) with loss of ileocecal
valve and recurrent episodes of diarrhea more than
3 times per day....................................
Partial colectomy with reanastomosis (reconnection 10
of the intestinal tube)............................
7330 Intestinal fistulous disease, external:
Requiring total parenteral nutrition (TPN); or 100
enteral nutrition along with at least one of the
following: (1) Daily discharge equivalent to four
or more ostomy bags, (2) requiring ten or more pad
changes per day, or (3) both a Body Mass Index
(BMI) less than 16 and persistent drainage (any
amount) for more than 1 month during the past 12
months.............................................
Requiring enteral nutritional support along with at 60
least one of the following: (1) Daily discharge
equivalent to three or less ostomy bags (sized 130
cc), (2) requiring fewer than ten pad changes per
day, or (3) a Body Mass Index (BMI) of 16 to 18
inclusive and persistent drainage (any amount) for
more than 2 months in the past 12 months...........
Intermittent fecal discharge with persistent 30
drainage for more than 3 months in the past 12
months.............................................
Note: This code applies to external fistulas that
have developed as a consequence of abdominal
trauma, surgery, radiation, malignancy, infection,
or ischemia........................................
* * * * * *
7332 Rectum and anus, impairment of sphincter control:
Complete loss of sphincter control characterized by 100
incontinence or retention that is not responsive to
a physician-prescribed bowel program and requires
either surgery or digital stimulation, medication
(beyond laxative use), and special diet; or
incontinence to solids and/or liquids two or more
times per day, which requires changing a pad two or
more times per day.................................
Complete or partial loss of sphincter control 60
characterized by incontinence or retention that is
partially responsive to a physician-prescribed
bowel program and requires either surgery or
digital stimulation, medication (beyond laxative
use), and special diet; or incontinence to solids
and/or liquids two or more times per week, which
requires wearing a pad two or more times per week..
Complete or partial loss of sphincter control 30
characterized by incontinence or retention that is
fully responsive to a physician-prescribed bowel
program and requires digital stimulation,
medication (beyond laxative use), and special diet;
or incontinence to solids and/or liquids two or
more times per month, which requires wearing a pad
two or more times per month........................
Complete or partial loss of sphincter control 10
characterized by incontinence or retention that is
fully responsive to a physician-prescribed bowel
program and requires medication or special diet; or
incontinence to solids and/or liquids at least once
every six months, which requires wearing a pad at
least once every six months........................
History of loss of sphincter control, currently 0
asymptomatic.......................................
Note: Complete or partial loss of sphincter control
refers to the inability to retain or expel stool at
an appropriate time and place.
7333 Rectum and anus, stricture of:
Inability to open the anus with inability to expel 100
solid feces........................................
Reduction of the lumen 50 percent or more, with pain 60
and straining during defecation....................
Reduction of the lumen by less than 50 percent, with 30
straining during defecation........................
Luminal narrowing with or without straining, managed 10
by dietary intervention............................
Note (1): Conditions rated under this code include
dyssynergic defecation (levator ani) and anismus
(functional constipation)
Note (2): Evaluate an ostomy as Intestine, large,
resection of (DC 7329).
7334 Rectum, prolapse of:
Persistent irreducible prolapse, repairable or 100
unrepairable.......................................
Manually reducible prolapse that is not repairable 50
and occurs at times other than bowel movements,
exertion, or while performing the Valsalva maneuver
Manually reducible prolapse that is not repairable 30
and occurs only after bowel movements, exertion, or
while performing the Valsalva maneuver.............
Spontaneously reducible prolapse that is not 10
repairable.........................................
Note (1): For repairable prolapse of the rectum,
continue the 100-percent evaluation for two months
following repair. Thereafter, determine the
appropriate evaluation based on residuals by
mandatory VA examination. Apply the provisions of
Sec. 3.105(e) of this chapter to any change in
evaluation based upon that or any subsequent
examination........................................
Note (2): Where impairment of sphincter control
constitutes the predominant disability, rate under
diagnostic code 7332 (Rectum and anus, impairment
of sphincter control)..............................
7335 Ano, fistula in, including anorectal fistula and
anorectal abscess:
More than two constant or near-constant fistulas 60
with abscesses, drainage, and pain, which are
refractory to medical and surgical treatment.......
One or two simultaneous fistulas, with abscess, 40
drainage, and pain.................................
Two or more simultaneous fistulas with drainage and 20
pain, but without abscesses........................
One fistula with drainage and pain, but without 10
abscess............................................
7336 Hemorrhoids, external or internal:
Internal or external hemorrhoids with persistent 20
bleeding and anemia; or continuously prolapsed
internal hemorrhoids with three or more episodes
per year of thrombosis.............................
Prolapsed internal hemorrhoids with two or less 10
episodes per year of thrombosis; or external
hemorrhoids with three or more episodes per year of
thrombosis.........................................
7337 Pruritus ani (anal itching):
[[Page 1545]]
With bleeding or excoriation........................ 10
Without bleeding or excoriation..................... 0
7338 Hernia, including femoral, inguinal, umbilical,
ventral, incisional, and other (but not including
hiatal).
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present for
12 months or more:
1. Size equal to 15 cm or greater in one dimension;
and
2. Pain when performing at least three of the 100
following activities: (1) Bending over, (2)
activities of daily living (ADLs), (3) walking, and
(4) climbing stairs................................
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present for
12 months or more:
1. Size equal to 15 cm or greater in one dimension;
and
2. Pain when performing two of the following 60
activities: (1) Bending over, (2) activities of
daily living (ADLs), (3) walking, and (4) climbing
stairs.............................................
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present for
12 months or more:
1. Size equal to 3 cm or greater but less than 15 cm
in one dimension; and
2. Pain when performing at least two of the 30
following activities: (1) Bending over, (2)
activities of daily living (ADLs), (3) walking, and
(4) climbing stairs................................
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present for
12 months or more:
1. Size equal to 3 cm or greater but less than 15 cm
in one dimension; and
2. Pain when performing one of the following 20
activities: (1) Bending over, (2) activities of
daily living (ADLs), (3) walking, and (4) climbing
stairs.............................................
Irreparable hernia (new or recurrent) present for 12 10
months or more; with hernia size smaller than 3 cm.
Asymptomatic hernia; present and repairable, or 0
repaired...........................................
Note (1): With two compensable inguinal hernias,
evaluate the more severely disabling hernia first,
and then add 10 percent to that rating to account
for the second compensable hernia. Do not add 10
percent to that rating if the more severely
disabling hernia is rated at 100-percent...........
Note (2): Any one of the following activities of
daily living are sufficient for evaluation:
Bathing, dressing, hygiene, and/or transfers.......
* * * * * *
7344 Benign neoplasms, exclusive of skin growths:
Evaluate under a diagnostic code appropriate to the
predominant disability or the specific residuals
after treatment....................................
Note: This diagnostic code includes lipoma,
leiomyoma, colon polyps, or villous adenoma........
7345 Chronic liver disease without cirrhosis:
Progressive chronic liver disease requiring use of 100
both parenteral antiviral therapy (direct antiviral
agents), and parenteral immunomodulatory therapy
(interferon and other); and for six months
following discontinuance of treatment..............
Progressive chronic liver disease requiring 60
continuous medication and causing substantial
weight loss and at least two of the following: (1)
Daily fatigue, (2) malaise, (3) anorexia, (4)
hepatomegaly, (5) pruritus, and (6) arthralgia.....
Progressive chronic liver disease requiring 40
continuous medication and causing minor weight loss
and at least two of the following: (1) Daily
fatigue, (2) malaise, (3) anorexia, (4)
hepatomegaly, (5) pruritus, and (6) arthralgia.....
Chronic liver disease with at least one of the 20
following: (1) Intermittent fatigue, (2) malaise,
(3) anorexia, (4) hepatomegaly, or (5) pruritus....
Previous history of liver disease, currently 0
asymptomatic.......................................
Note (1): 100-percent evaluation shall continue for
six months following discontinuance of parenteral
antiviral therapy and administration of parenteral
immunomodulatory drugs. Six months after
discontinuance of parenteral antiviral therapy and
parenteral immunomodulatory drugs, determine the
appropriate disability rating by mandatory VA exam.
Apply the provisions of Sec. 3.105(e) to any
change in evaluation based upon that or any
subsequent examination.............................
Note (2): For individuals for whom physicians
recommend both parenteral antiviral therapy and
parenteral immunomodulatory drugs, but for whom
treatment is medically contraindicated, rate
according to DC 7312 (Cirrhosis of the liver)......
Note (3): This diagnostic code includes Hepatitis B
(confirmed by serologic testing), primary biliary
cirrhosis (PBC), primary sclerosing cholangitis
(PSC), autoimmune liver disease, Wilson's disease,
Alpha-1-antitrypsin deficiency, hemochromatosis,
drug-induced hepatitis, and non-alcoholic
steatohepatitis (NASH). Track Hepatitis C (or non-
A, non-B hepatitis) under DC 7354 but evaluate it
using the criteria above...........................
Note (4): Evaluate sequelae, such as cirrhosis or
malignancy of the liver, under an appropriate
diagnostic code, but do not use the same signs and
symptoms as the basis for evaluation under DC 7354
and under a diagnostic code for sequelae. (See Sec.
4.14)............................................
7346 Hiatal hernia and paraesophageal hernia:
Rate as esophagus, stricture of (DC 7203).
7347 Pancreatitis, chronic:
Daily episodes of abdominal or mid-back pain that 100
require three or more hospitalizations per year;
and pain management by a physician; and
maldigestion and malabsorption requiring dietary
restriction and pancreatic enzyme supplementation..
Three or more episodes of abdominal or mid-back pain 60
per year and at least one episode per year
requiring hospitalization for management either of
complications related to abdominal pain or
complications of tube enteral feeding..............
At least one episode per year of abdominal or mid- 30
back pain that requires ongoing outpatient medical
treatment for pain, digestive problems, or
management of related complications including but
not limited to cyst, pseudocyst, intestinal
obstruction, or ascites............................
Note (1): Appropriate diagnostic studies must
confirm that abdominal pain in this condition
results from pancreatitis..........................
Note (2): Separately rate endocrine dysfunction
resulting in diabetes due to pancreatic
insufficiency under DC 7913 (Diabetes mellitus)....
7348 Vagotomy with pyloroplasty or gastroenterostomy:
Following confirmation of postoperative 40
complications of stricture or continuing gastric
retention..........................................
With symptoms and confirmed diagnosis of alkaline 30
gastritis, or with confirmed persisting diarrhea...
With incomplete vagotomy............................ 20
[[Page 1546]]
Note: Rate recurrent ulcer following complete
vagotomy under DC 7304 (Peptic ulcer disease), with
a minimum rating of 20 percent; and rate post-
operative residuals not addressed by this
diagnostic code under DC 7303 (Chronic
complications of upper gastrointestinal surgery)...
7350 Liver abscess:
Assign a rating of 100 percent for 6 months from the
date of initial diagnosis. Six months following
initial diagnosis, determine the appropriate
disability rating by mandatory VA examination.
Thereafter, rate the condition based on chronic
residuals under the appropriate body system. Apply
the provisions of Sec. 3.105(e) to any reduction
in evaluation......................................
Note: This diagnostic code includes abscesses caused
by bacterial, viral, amebic (e.g., E. hystolytica),
fungal (e.g., C. albicans), and other agents.......
7351 Liver transplant:
For an indefinite period from the date of hospital 100
admission for transplant surgery...................
Awaiting retransplantation, minimum rating.......... 60
Minimum rating...................................... 30
Note: Assign a rating of 100 percent as of the date
of hospital admission for transplant surgery. One
year following discharge, determine the appropriate
disability rating by mandatory VA examination.
Apply the provisions of Sec. 3.105(e) of this
chapter to any change in evaluation based upon that
or any subsequent examination. Rate residuals of
any recurrent underlying liver disease under the
appropriate diagnostic code and, when appropriate,
combine with other post-transplant residuals under
the appropriate body system(s), subject to the
provisions of Sec. Sec. 4.14 and 4.114..........
7352 Pancreas transplant:
For an indefinite period from the date of hospital 100
admission for transplant surgery...................
Minimum rating...................................... 30
Note: Assign a rating of 100 percent as of the date
of hospital admission for transplant surgery. One
year following discharge, determine the appropriate
disability rating by mandatory VA examination.
Apply the provisions of Sec. 3.105(e) of this
chapter to any change in evaluation based upon that
or any subsequent examination......................
7354 Hepatitis C (or non-A, non-B hepatitis):
Rate under DC 7345 (Chronic liver disease without
cirrhosis).
7355 Celiac disease:
Malabsorption syndrome that causes weakness which 80
interferes with activities of daily living; and
weight loss resulting in wasting and nutritional
deficiencies; and with systemic manifestations
including but not limited to, weakness and fatigue,
dermatitis, lymph node enlargement, hypocalcemia,
low vitamin levels; and anemia related to
malabsorption; and episodes of abdominal pain and
diarrhea due to lactase deficiency or pancreatic
insufficiency......................................
Malabsorption syndrome that causes chronic diarrhea 50
managed by medically-prescribed dietary
intervention such as prescribed gluten-free diet,
with nutritional deficiencies due to lactase and
pancreatic insufficiency; and with systemic
manifestations including, but not limited to,
weakness and fatigue, dermatitis, lymph node
enlargement, hypocalcemia, low vitamin levels, or
atrophy of the inner intestinal lining shown on
biopsy.............................................
Malabsorption syndrome with chronic diarrhea managed 30
by medically-prescribed dietary intervention such
as prescribed gluten-free diet; and without
nutritional deficiencies...........................
Note (1): An appropriate serum antibody test or
endoscopy with biopsy must confirm the diagnosis.
Note (2): For evaluation of celiac disease with the
predominant disability of malabsorption, use the
greater evaluation between DC 7328 or celiac
disease under DC 7355.
7356 Gastrointestinal dysmotility syndrome:
Requiring complete dependence on total parenteral 80
nutrition (TPN) or continuous tube feeding for
nutritional support................................
Requiring intermittent tube feeding for nutritional 50
support; with recurrent emergency treatment for
episodes of intestinal obstruction or regurgitation
due to poor gastric emptying, abdominal pain,
recurrent nausea, or recurrent vomiting............
With symptoms of intestinal pseudo-obstruction 30
(CIPO); and symptoms of intestinal motility
disorder, including but not limited to, abdominal
pain, bloating, feeling of epigastric fullness,
dyspepsia, nausea and vomiting, regurgitation,
constipation, and diarrhea, managed by ambulatory
care; and requiring prescribed dietary management
or manipulation....................................
Intermittent abdominal pain with epigastric fullness 10
associated with bloating; and without evidence of a
structural gastrointestinal disease................
Note: Use this diagnostic code for illnesses
associated with 38 CFR 3.317(a)(2)(i)(B)(3), other
than those which can be evaluated under DC 7319....
7357 Post pancreatectomy syndrome:
Following total or partial pancreatectomy, evaluate 30
under Pancreatitis, chronic (DC 7347), Chronic
complications of upper gastrointestinal surgery (DC
7303), or based on residuals such as malabsorption
(Intestine, small, resection of, DC 7328), diarrhea
(Irritable bowel syndrome, DC 7319, or Crohn's
disease or undifferentiated form of inflammatory
bowel disease, DC 7326), or diabetes (DC 7913),
whichever provides the highest evaluation. Minimum.
------------------------------------------------------------------------
0
6. Amend appendix A to part 4 by:
0
a. Adding entries for Sec. Sec. 4.110, 4.111 and 4.112;
0
b. In the entry for Sec. 4.114:
0
i. Adding in numerical order entries for diagnostic codes 7200 through
7207 and 7301 through 7303;
0
ii. Revising the entries for diagnostic codes 7304 through 7305;
0
iii. Adding in numerical order entries for diagnostic codes 7306 and
7307;
0
iv. Revising the entry for diagnostic code 7308;
0
v. Adding in numerical order entries for diagnostic codes 7309 and
7310;
0
vi. Revising the entry for diagnostic code 7312;
0
vii. Adding in numerical order entries for diagnostic codes 7314
through 7318;
0
viii. Revising the entries for diagnostic codes 7319 and 7321;
0
ix. Adding in numerical order entries for diagnostic codes 7322 through
7327;
0
x. Revising the entries for diagnostic codes 7328 through 7330 and
7332;
0
xi. Adding in numerical order an entry for diagnostic code 7333;
0
xii. Revising the entry for diagnostic codes 7334;
0
xiii. Adding in numerical order entries for diagnostic codes 7335
through 7338;
0
xiv. Revising the entry for diagnostic code 7339;
0
xv. Adding in numerical order an entry for diagnostic code 7340;
0
xvi. Revising the entries for diagnostic codes 7344 through 7348;
0
xvii. Adding in numerical order an entry for diagnostic code 7350;
[[Page 1547]]
0
xviii. Revising the entry for diagnostic code 7351;
0
xix. Adding in numerical order an entry for diagnostic code 7352;
0
xx. Revising the entry for diagnostic code 7354; and
0
xxi. Adding in numerical order entries for diagnostic codes 7355
through 7357;
The revisions and additions read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946
----------------------------------------------------------------------------------------------------------------
Diagnostic
Sec. code No.
----------------------------------------------------------------------------------------------------------------
* * * * * * *
4.110.................................... .............. Removed and reserved [Effective date of final rule].
4.111.................................... .............. Removed and reserved [Effective date of final rule].
4.112.................................... .............. Revised [Effective date of final rule].
* * * * * * *
4.114.................................... .............. Introduction paragraph revised March 10, 1976;
introduction paragraph revised [Effective date of
final rule].
7200 Title, criterion [Effective date of final rule].
7201 Criterion [Effective date of final rule].
7202 Evaluation, criterion, note [Effective date of final
rule].
7203 Evaluation, criterion, note [Effective date of final
rule].
7204 Title, note [Effective date of final rule].
7205 Note [Effective date of final rule].
7206 Added [Effective date of final rule].
7207 Added [Effective date of final rule].
7301 Title, Evaluation, criterion, note [Effective date of
final rule].
7302 Removed April 8, 1959.
7303 Added [Effective date of final rule].
7304 Evaluation November 1, 1962; title, evaluation,
criterion, and note [Effective date of final rule].
7305 Evaluation November 1, 1962; Removed [Effective date
of final rule].
7306 Criterion April 8, 1959; Removed [Effective date of
final rule].
7307 Evaluation May 22, 1964; Criterion May 22, 1964; Note
May 22, 1964; title, evaluation, criterion, and note
[Effective date of final rule].
7308 Title April 8, 1959; evaluation April 8, 1959;
evaluation and criterion [Effective date of final
rule].
7309 Evaluation [Effective date of final rule].
7310 Evaluation [Effective date of final rule].
* * * * * * *
7312 Evaluation March 10, 1976; evaluation July 2, 2001;
title, evaluation, criterion, and note [Effective
date of final rule].
7314 Title, evaluation, note [Effective date of final
rule].
7315 Evaluation [Effective date of final rule].
7316 Removed [Effective date of final rule].
7317 Note [Effective date of final rule].
7318 Title, evaluation, and criterion [Effective date of
final rule].
7319 Title November 1, 1962; evaluation November 1, 1962;
title, evaluation, criterion, and note [Effective
date of final rule].
7321 Evaluation July 6, 1950; criterion March 10, 1976;
Removed [Effective date of final rule].
7322 Removed [Effective date of final rule].
7323 Criterion and note [Effective date of final rule].
7324 Removed [Effective date of final rule].
7325 Note November 1, 1962; note [Effective date of final
rule].
7326 Note November 1, 1962; title, evaluation, criterion
and note [Effective date of final rule].
7327 Evaluation November 1, 1962; criterion November 1,
1962; note November 1, 1962; title, evaluation,
criterion, and note [Effective date of final rule].
7328 Evaluation November 1, 1962; title, evaluation,
criterion, and note [Effective date of final rule].
7329 Evaluation November 1, 1962; evaluation, criterion,
and note [Effective date of final rule].
7330 Evaluation November 1, 1962; criterion and note
[Effective date of final rule].
* * * * * * *
7332 Evaluation November 1, 1962; evaluation, criterion,
and note [Effective date of final rule].
7333 Evaluation, criterion, and note [Effective date of
final rule].
7334 Evaluation July 6, 1950; evaluation November 1, 1
[…truncated; see source link]Indexed from Federal Register on January 11, 2022.
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