Proposed Rule2022-02051
Schedule for Rating Disabilities: Mental Disorders
Primary source
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Published
February 15, 2022
Issuing agencies
Veterans Affairs Department
Abstract
The Department of Veterans Affairs (VA) proposes to amend the portion of the rating schedule dealing with mental disorders, including revising the General Rating Formula for Mental Disorders and combining currently separate General Rating Formula for Mental Disorders with the General Rating Formula for Eating Disorders in the VA Schedule for Rating Disabilities (VASRD or rating schedule). The proposed rule reflects changes made by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), advances in medical knowledge, and recommendations from VA's Mental Disorders Work Group.
Full Text
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<title>Federal Register, Volume 87 Issue 31 (Tuesday, February 15, 2022)</title>
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[Federal Register Volume 87, Number 31 (Tuesday, February 15, 2022)]
[Proposed Rules]
[Pages 8498-8506]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-02051]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AQ82
Schedule for Rating Disabilities: Mental Disorders
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the
portion of the rating schedule dealing with mental disorders, including
revising the General Rating Formula for Mental Disorders and combining
currently separate General Rating Formula for Mental Disorders with the
General Rating Formula for Eating Disorders in the VA Schedule for
Rating Disabilities (VASRD or rating schedule). The proposed rule
reflects changes made by the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5),
advances in medical knowledge, and recommendations from VA's Mental
Disorders Work Group.
DATES: VA must receive comments on or before April 18, 2022.
ADDRESSES: Comments may be submitted through <a href="http://www.Regulations.gov">www.Regulations.gov</a>.
Comments received will be available at <a href="http://www.Regulations.gov">www.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#6755565637080b0e041e3413060101493105061106040827110649000811"><span class="__cf_email__" data-cfemail="41737070112e2d28223812352027276f1723203720222e0137206f262e37">[email protected]</span></a>,
(202) 461-9700. (This is not a toll-free telephone number.)
SUPPLEMENTARY INFORMATION:
I. The Need for Updated Rating Criteria
As part of its ongoing revision of the VASRD, VA proposes changes
to the rating schedule for mental disorders, including the General
Rating Formula for Mental Disorders codified at 38 CFR 4.130. The
proposed changes would update evaluation criteria based on the DSM-5,
medical advances since the last substantive revision of the rating
schedule for mental disorders in 1996, and current understanding of
functional impairment associated with, or resulting from, mental
disorders. These changes also reflect comments received from subject
matter experts in the Veterans Benefits Administration (VBA), Veterans
Health Administration (VHA), Board of Veterans' Appeals (BVA),
Department of Defense (DoD), and Veterans Service Organizations (VSOs).
Overall, VA did not rely on one particular input for these proposed
changes, but the multitude of published, publicly available, and peer-
reviewed, scientific and medical sources cited below.
In 2006, the Veterans' Disability Benefits Commission (VDBC) asked
the Institute of Medicine (IOM) (now named the National Academy of
Medicine) to study and recommend improvements for the VASRD. The IOM
recommended updating the medical content of the rating schedule, by
placing greater emphasis on a disabled veteran's ability to function in
the work setting, rather than focusing on symptoms alone. Institute of
Medicine, ``A 21st Century System for Evaluating Veterans for
Disability Benefits'' 113-14 (Michael McGeary et al. eds., 2007).
In March 2015, VA published a final rule (RIN 2900-AO96) that
updated the nomenclature for mental disorders and removed outdated
references to the fourth editions of DSM (DSM-IV and DSM-IV-TR),
replacing them with references to the latest fifth edition (DSM-5).
While this rule updated the nomenclature to conform to the DSM-5, VA
did not update the rating criteria used to evaluate mental disorders.
VA now proposes, however, to update the rating criteria for mental
disorders in accord with IOM's recommendation and the latest medical
science. VA's updates are based on the framework associated with the
International Classification of Functioning, Disability, and Health
(ICF) and its companion assessment instrument, the World Health
Organization (WHO) Disability Assessment Schedule 2.0 (WHODAS 2.0), as
well as the International Classification of Diseases (ICD), and
concepts and methodology from the DSM-5.
The WHODAS 2.0 is a validated instrument that assesses health and
disability across all diseases, including mental, neurological, and
addictive disorders. O. Garin et al., ``Validation of the `World Health
Organization Disability Assessment Schedule, WHODAS-2' in patients with
chronic diseases,'' 8 Health and Quality of Life Outcomes 51 (2010). It
assesses the ability to perform tasks in six functional domains by
measuring the impact of a disability across various life functions and
assigning a score for each domain. ``WHO Disability Assessment Schedule
2.0 (WHODAS 2.0),'' World Health Organization, <a href="https://www.who.int/classifications/icf/whodasii/en/">https://www.who.int/classifications/icf/whodasii/en/</a> (last visited Nov. 19, 2019)
(hereinafter ``WHODAS 2.0'').
The ICD is a standard tool for the diagnosis of disabilities for
the purposes of epidemiology, health management, and clinical practice.
By employing a standardized numerical labeling system, the ICD allows
disease to be classified, monitored, and analyzed for statistical
purposes. ``Classifications,'' World Health Organization, <a href="https://www.who.int/classifications/en/">https://www.who.int/classifications/en/</a> (last visited Nov. 19, 2019).
Finally, the DSM-5 is a standardized classification of mental
disorders for mental health professionals in the
[[Page 8499]]
United States. The DSM-5 contains every mental health disorder
recognized by the American Psychiatric Association and provides
detailed diagnostic criteria. As a standard for mental health, the DSM-
5 is also used to collect data regarding public health matters
involving psychiatric disorders. See generally American Psychiatric
Association (APA), ``Diagnostic and Statistical Manual of Mental
Disorders'' (American Psychiatric Publishing, 5th ed. 2013)
(hereinafter ``DSM-5'').
Previous versions of the DSM relied upon a categorical diagnostic
classification scheme requiring a clinician to determine whether a
disorder was absent or present with a multiaxial system, each axis of
which gave a different type of information about the diagnosis. Axis V,
in particular, was comprised of the Global Assessment of Functioning
(GAF) scale, which was used by clinicians to assess an individual's
overall level of functioning on a hypothetical continuum of mental
health illness.
The DSM-5 eliminates the multiaxial approach and instead provides
for a ``dimensional approach, which allows a clinician more latitude to
assess the severity of a condition.'' APA, ``DSM-5's Integrated
Approach to Diagnosis and Classifications,'' <a href="https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Integrated-Approach.pdf">https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Integrated-Approach.pdf</a>. According to the APA, a growing body of
scientific evidence supports multi-faceted or multi-dimensional
concepts in assessing functional impairment due to mental disorders.
DSM-5 at 733-737. Clinicians who assess the consequences of mental
disorders should consider a combination of all domains of functioning,
and a comprehensive approach incorporates variations of features within
the individual, rather than relying on a simple combination of
presented symptoms. Id.
This dimensional approach incorporates differential severity of
individual symptoms both within and outside of a disorder's diagnostic
criteria as measured by intensity, duration, or number of symptoms,
along with other features such as type and severity of disabilities.
DSM-5 at 733. In sum, the dimensional approach is consistent with
current diagnostic practice and comprehensively examines the functional
consequences of a mental disability. Id.; see Lonnie R. Bristow,
Preface to ``A 21st Century System for Evaluating Veterans for
Disability Benefits'' xii (some of the signature injuries incurred in
Operations Enduring Freedom/Iraqi Freedom, such as posttraumatic stress
disorder (PTSD), must be evaluated in terms of their functional
consequences). Accordingly, the DSM-5 now advocates for assessments
like the WHODAS 2.0, which ``has proven useful as a standardized
measure of disability for mental disorders.'' DSM-5 at 21. The WHODAS
2.0 corresponds to concepts contained in the WHO's ICF. T. Bedirhan
[Uuml]st[uuml]n et al., ``Developing the World Health Organization
Disability Assessment Schedule 2.0,'' Bull. World Health Organ. 815
(2010) (hereinafter ``Developing WHODAS 2.0''). The WHODAS 2.0 does not
depend on symptom levels. Rather, the WHODAS 2.0 is a 36-item or 12-
item measure that assesses an individual's performance over the past 30
days in activities in the following six domains (areas of functioning):
(1) Understanding and communication; (2) getting around; (3) self-care;
(4) getting along with people; (5) life activities; and (6)
participation in society. World Health Organization, ``Measuring Health
and Disability Manual for WHO Disability Assessment Schedule WHODAS
2.0'' 4-5 (T.B. [Uuml]st[uuml]n et al. eds., 2010) (hereinafter
``Manual''). The WHODAS 2.0 asks how much difficulty the individual has
had performing certain activities within each domain using the
following scale: No difficulty (1), mild difficulty (2), moderate
difficulty (3), severe difficulty (4), and extreme difficulty or cannot
do (5). Id. at 38, 41.
The WHODAS 2.0 is similar to the Clinician-Administered PTSD Scale
for DSM-5 (CAPS-5), which is the ``gold standard in PTSD assessment.''
See Frank W. Weathers et al., ``The Clinician-Administered PTSD Scale
for DSM-5 (CAPS-5)'' (2013), cited at <a href="https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp">https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp</a> (last visited Nov. 19, 2019)
(hereinafter ``Weathers 2013''); Frank W. Weathers et al., ``The
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and
Initial Psychometric Evaluation in Military Veterans,'' Psychol.
Assess. 30(3) (2018), available at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805662/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805662/</a> (last visited Nov. 19, 2019). The CAPS-5 is a 30-
item structured interview administered by clinicians and clinical
researchers that is used to render a diagnosis of PTSD and assess the
severity of the 20 PTSD symptoms in the DSM-5 based on symptom
frequency and intensity using a scale similar to the WHODAS 2.0, i.e.,
absent (0), mild (1), moderate (2), severe (3), and extreme (4). See
Weathers 2013, supra. The scores for frequency and intensity are
combined to form a single severity score for each symptom, and a total
severity score is calculated by combining all the individual severity
scores for the 20 PTSD symptoms. Id.
There is evidence that a standardized assessment for disability
related to mental disorders, such as the WHODAS 2.0 and CAPS-5, leads
to a more reliable and valid disability examination process. IOM,
``Psychological Testing in the Service of Disability Determination'' 66
(2015), <a href="https://www.nap.edu/read/21704">https://www.nap.edu/read/21704</a>. The WHODAS 2.0 ``has good
psychometric qualities, including good reliability and item-response
characteristics'' and shows concurrent validity when compared with
other measures of disability or health status or with clinician
ratings. Developing WHODAS 2.0, supra. A VA study compared clinical
interviews with standardized assessments that incorporated the CAPS-5
for PTSD diagnosis and the WHODAS 2.0 for functional impairment and
found that administering a standardized disability assessment resulted
in more complete assessment of functional impairment and diagnostic
coverage of PTSD. Ted Speroff et al., ``Compensation and Pension
Examination for PTSD,'' VA Office of Health Services Research &
Development Service Forum 7 (May 2012). VA therefore proposes a General
Rating Formula for Mental Disorders, h is explained below, that would
provide a standardized assessment of disability similar to the WHODAS
2.0 and CAPS-5. It would also create a common language between
clinicians and adjudicators, which VA believes will lead to more
efficient and accurate adjudication of claims for mental disorders.
Another important purpose for updated rating criteria is the fact
that, since September 11, 2001, the United States has deployed more
than 2.5 million American service members to Iraq, Afghanistan, and
other dangerous regions around the world. These deployments have
exposed service members to a variety of stressors, including sustained
risk of, and exposure to, injury and death, as well as an array of
family pressures. U.S. Department of Defense, ``DoD, VA, Other Agencies
Team to Study PTSD, TBI,'' American Forces Press Service (Aug. 14,
2013) <a href="https://archive.defense.gov/News/NewsArticle.aspx?ID=120620">https://archive.defense.gov/News/NewsArticle.aspx?ID=120620</a> (last
visited Nov. 19, 2019). Multiple deployments involve prolonged exposure
to combat-related stressors. The psychological toll of these
deployments must be taken seriously. RAND Corporation, Preface to
``Invisible Wounds of War: Psychological and Cognitive Injuries, Their
Consequences, and Services to Assist Recovery'' iii (T.
[[Page 8500]]
Tanielian & L.H. Jaycox eds., 2008). Recent reports have referred to
PTSD and traumatic brain injury (TBI) as the signature wounds of the
conflicts in Afghanistan and Iraq. Id. With increasing incidence of
suicide and suicide attempts among returning veterans, concern about
depression and other mental health disorders is also on the rise.
Indeed, individuals with mental disorders such as depression,
anxiety and adjustment disorders frequently experience recurrent
absences from work. I. Arends et al., ``Prevention of Recurrent
Sickness Absence in Workers with Common Mental Disorders: Results of a
Cluster-Randomized Controlled Trial,'' 71 Occupational Envtl Med. 21
(2014). As compared to physical disorders, mental disorders cause less
engagement in life activities, including work. M.A. Buist-Bouwman et
al., ``Comparing Functioning Associated with Mental and Physical
disorders,'' 113 Acta Psychiatr. Scand. 499 (2006). One comprehensive
study based on a WHO questionnaire estimated that employees with
bipolar disorder lost the equivalent of about 28 work days annually
from sick time and other absences. ``Mental health problems in the
workplace,'' Harvard Mental Health Letter (Feb. 2010), <a href="https://www.health.harvard.edu/newsletter_article/mental-health-problems-in-the-workplace">https://www.health.harvard.edu/newsletter_article/mental-health-problems-in-the-workplace</a>; see also N.L. Kleinman et al., ``Lost Time, Absence
Costs, and Reduced Productivity Output for Employees With Bipolar
Disorder,'' 47 J. Occupational & Envtl. Med. 1117, 1121 (Nov. 2005).
Moreover, compared to the general population, the risk of recurrent
sickness absence is higher for employees with mental disorders, and
such recurrent absences are often more serious and long-lasting. See 71
Occupational Envtl Med. at 21.
As the understanding of mental disorders has advanced, so has the
ability to recognize and quantify the components that form both the
diagnosis as well as its attendant disability. Therefore, VA proposes
to update the section of the rating schedule that addresses mental
disorders to provide clear, consistent, and accurate evaluation
criteria. Updating the General Rating Formula for Mental Disorders will
also improve the timeliness and accuracy of adjudications by providing
uniform objective criteria based on modern medical science.
Finally, the proposed changes are necessary to address potential
inadequacies in the current mental health criteria of the VASRD. In
August 2007, the Center for Naval Analyses (CNA) prepared an earnings
loss study in response to a request from the VDBC to assess
compensation levels under the VASRD. Eric Christensen et al., ``Final
Report for the Veterans' Disability Benefits Commission: Compensation,
Survey Results, and Selected Topics'' (CNA 2007). The study found that
those veterans with primary mental disabilities do not receive adequate
compensation to offset any earnings losses. Id. at 193. On the basis of
its findings, CNA recommended that VA review and adjust evaluations for
mental disorders to provide adequate compensation for earnings losses.
Id.
Another study, completed by Economic Systems, Inc. (EconSys), in
September 2008, focused on the adequacy of VA benefits to compensate
for loss of earnings and functional impairment. EconSys, ``A Study of
Compensation Payments for Service-Connected Disabilities'' (2008). Like
CNA, EconSys found that veterans with mental disorders generally were
undercompensated by the VASRD. Id. at 33. EconSys also recommended a
re-evaluation of the criteria for mental disorders, noting that VA
should update the VASRD to reflect modern medical science. Id at 35.
Given the foregoing, VA proposes to adopt new evaluation criteria
that more accurately capture the occupational impairment caused by
mental disabilities and provide more adequate compensation for the
earnings losses experienced by veterans with service-connected mental
disorders. A more detailed discussion of the specific evaluation
criteria VA proposes and how VA will apply it follows.
II. The Current Rating Schedule and a New Framework for Evaluation
The current rating schedule for mental disorders provides two
separate rating formulas, the General Rating Formula for Mental
Disorders and the Rating Formula for Eating Disorders. The General
Rating Formula for Mental Disorders bases evaluations on a list of
signs and symptoms that characteristically produce a particular level
of disability. 61 FR 52695, 52700 (Oct. 8, 1996). VA believes that an
updated formula considering the severity, frequency and duration of
symptoms would provide the most accurate and consistent method for
evaluating functional impairment.
The current Rating Formula for Eating Disorders bases evaluations
on the extent of weight loss, incapacitating episodes, and required
periods of hospitalization, in accordance with the now-outdated DSM-IV.
60 FR 54825, 54829 (Oct. 26, 1995). VA believes that an updated formula
can better evaluate how symptoms or episodes attributable to eating
disorders actually translate into functional and occupational
impairment.
As noted above, the understanding of disability resulting from
mental disorders has evolved with the science. The IOM report
recognized that some of the signature injuries (e.g., PTSD) incurred in
Operations Enduring Freedom/Iraqi Freedom are not visible or subject to
a laboratory test. See also Bristow, supra. Instead, they must be
evaluated in terms of their functional consequences. Id. In that
regard, properly evaluating mental disability requires the ability to
recognize and quantify the components that form the diagnosis as well
as resulting impairment. While symptoms determine the diagnosis, they
do not necessarily translate directly to functional impairment. Thus,
we believe that, in order to accurately measure functional impairment,
VA must consider the frequency and severity of the symptoms and how
they impact functioning and performance across a variety of domains:
That, is aspects of human behavior and functioning.
To ensure evaluations are accurate and consistent with modern
medicine, VA is proposing a new, comprehensive general rating formula
for all mental disorders, to include eating disorders. The proposed
evaluation criteria will measure a veteran's essential ability to
participate in the work environment and the impact of the mental
disorder on earning capacity via a comprehensive assessment of
occupational and social functioning. Diagnoses must still be
established according to the DSM-5. 38 CFR 4.125(a). However, once an
examiner has diagnosed a specific mental disorder, the proposed rating
criteria will enable VA to assign an evaluation by analyzing the
frequency, intensity, and overall severity of occupational and social
impairment due to the diagnosed mental disorder and in accordance with
the updated clinical standards of the DSM-5.
The proposed evaluation criteria, as further discussed below,
encapsulate the dimensional approach of the WHODAS 2.0, ICD, DSM-5, and
CAPS-5.
III. The Proposed General Rating Formula for Mental Disorders
A. Domains of Functional Impairment
Congress requires VA to base its rating schedule, ``as far as
practicable, upon the average impairments of earning capacity'' in
``civil occupations'' that a veteran will experience due to the
[[Page 8501]]
disability in question. 38 U.S.C. 1155. VA recognizes that a veteran's
earning capacity after disability is highly dependent upon both
occupational and social functioning. Studies have shown that the
objective evaluation of functional performance, rather than subjective
criteria, is a strong predictor of impairment in earning capacity in
individuals with a diagnosed mental disorder. A. Galvao et al.,
``Predicting Improvement in Work Status of Patients With Chronic Mental
Illness After Vocational and Integrative Rehabilitation Measurements,''
44 Rehabilitation 208, 208-14 (2005). VA has therefore determined that
a multidimensional approach to evaluating mental disorders will provide
the most efficient and satisfactory method for measuring the impact of
mental health disabilities on a veteran's earning capacity.
VA would continue to require that a diagnosis of a mental disorder
be established in accordance with the DSM-5 as required by 38 CFR
4.125(a). However, for purposes of rating the extent of disability
attributable to a mental disorder, VA proposes a rating formula using
five domains of functioning to evaluate the extent of disability,
similar to the approach of the WHODAS 2.0.
As explained above, the WHODAS 2.0 assesses an individual's ability
to perform life activities based upon six domains (areas of
functioning): (1) Understanding and communicating, (2) ability to move
and get around, (3) caring for oneself, (4) getting along with people,
(5) carrying out life activities, and (6) participating in society.
However, ``getting along with people'' and ``participation in society''
can essentially be categorized as one domain of ``interpersonal
interactions and relationships'' for VA's purpose of evaluating a
veteran's earning capacity. 38 U.S.C. 1155. Therefore, the proposed
General Rating Formula for Mental Disorders would evaluate the extent
of a veteran's disability based upon all evidence of record relevant to
the following five domains: (1) Cognition (i.e., understanding and
communicating), (2) interpersonal interactions and relationships (i.e.,
interacting with people and participating in society), (3) task
completion and life activities, (4) navigating environments (i.e.,
getting around), and (5) self-care.
The domain of ``Cognition'' would assess a veteran's mental
processing involved in gaining knowledge and comprehension. These
processes include, but are not limited to, memory, concentration,
attention, goal setting, speed of processing information, planning,
organizing, prioritizing, problem solving, judgment, decision making,
or flexibility in adapting when appropriate.
The domain of ``Interpersonal Interactions and Relationships''
would assess a veteran's ability to effectively interact with other
people in both social and occupational settings and participate in
society. This domain includes both informal (social, associational,
etc.) and formal (coworkers, supervisors, etc.) relationships.
The domain of ``Task Completion and Life Activities'' would assess
a veteran's ability to manage task-related demands. This domain
includes, but is not limited to, the following types of activities:
Vocational, educational, domestic chores, social, or caregiving.
The domain of ``Navigating Environments'' would assess a veteran's
physical and mental ability to go from place to place. This domain
includes, but is not limited to, the following: leaving the home, being
in confined or crowded spaces, independently moving in surroundings,
navigating new environments, driving, or using public transportation.
The domain of ``Self-Care'' would assess a veteran's ability to
take care of himself or herself. This domain would include, but would
not be limited to, the following types of activities: Hygiene, dressing
appropriately, or nourishment.
B. Assessing the Level of Functioning
In order to accurately measure occupational and social impairment
due to a mental disorder, VA proposes to measure a veteran's
functioning within each of the five domains discussed above based upon
the level of difficulty the veteran experiences in performing tasks
associated with the domain (intensity) and the percentage of time that
these difficulties occur (frequency). See Jon D. Elhai et al.,
``Posttraumatic Stress Disorder's Frequency and Intensity Ratings Are
Associated With Factor Structure Differences in Military Veterans,'' 22
Psychol. Assess. 723 (2010); A.J. Rush, Jr., et al., ``Handbook of
Psychiatric Measures'' 103-05 (American Psychiatric Publishing, 2d ed.
2008). This approach would be outlined in 38 CFR 4.126(a), which will
state that, when evaluating a mental disorder, an adjudicator must
consider the intensity and frequency of psychiatric symptoms that bear
on the five domains discussed above. Section 4.126(a) would also state
that VA will assess the intensity and frequency of symptoms in each
domain and will assign an evaluation based on the combined levels of
functioning in these domains as explained in the General Rating Formula
For Mental Disorders. VA would delete paragraph (b) of current section
4.126, which provides that VA will consider social impairment but will
not assign an evaluation ``solely on the basis of social impairment,''
as obsolete, because that principle would be more clearly addressed in
one of the domains for assessment, providing for consideration of
``interpersonal interactions and relationships.'' Paragraphs (c) and
(d) would be redesignated as paragraphs (b) and (c), respectively.
As to the proposed General Rating Formula, there will be 100, 70,
50, 30, and 10 percent evaluations based on the severity of impairment
in all five domains. To measure the severity in an individual domain,
VA will first evaluate the intensity of impairment in that domain.
Intensity refers to the difficulties in functioning, i.e., interference
with completing tasks. The levels of intensity for each domain will be
none, mild, moderate, severe, or total, generally defined as follows:
``None''--``No difficulties'' associated with the domain;
``Mild''--``Slight difficulties in one or more aspects'' of the
domain that ``do not interfere with tasks, activities, or
relationships;''
``Moderate''--``Clinically significant difficulties in one or
more aspects'' of the domain ``that interfere with tasks,
activities, or relationships;''
``Severe''--``Serious difficulties in one or more aspects'' of
the domain ``that interfere with tasks, activities, or
relationships;''
``Total''--``Profound difficulties in one or more aspects'' of
the domain ``that cannot be managed or remediated; incapable of even
the most basic tasks within one or more aspects'' of the domain;
``difficulties that completely interfere with tasks, activities, or
relationships.''
As a technical note, the ``task completion and life activities''
domain uses slightly different criteria to define these levels, and
several of the domains consider the effect of accommodations or
assistance in their assessment.
When evaluating intensity under the proposed criteria, examiners
and VA adjudicators should be cognizant of the fact that some symptoms
may overlap between domains. VA will provide training or additional
guidance to help avoid the artificial inflation of the severity of a
condition through the double-counting of symptoms. Cf. 38 CFR 4.14.
Moreover, consistent with 38 U.S.C. 1155 (VASRD shall compensate for
impairments in earning capacity), examiners and VA adjudicators
generally should assess impairments with a view toward their effect on
earning capacity. Finally, examiners and
[[Page 8502]]
VA adjudicators generally should assess impairments due to the service-
connected disability, not other causes. See ICF Checklist (Version
2.1a, Clinician Form) (``The level of capacity should be judged
relative to that normally expected of the person, or the person's
capacity before they acquired their health condition.''), <a href="https://www.who.int/classifications/icf/icfchecklist.pdf?ua=1">https://www.who.int/classifications/icf/icfchecklist.pdf?ua=1</a>; see also Manual
at 39 (WHODAS 2.0 responses should address difficulties with activities
due to health conditions, rather than to other causes). Again, training
and additional guidance will be provided to VA personnel for further
edification on appropriately applying the revised general rating
formula.
After determining the intensity for each domain, VA would address
frequency. Frequency refers to the percentage of time, in the past
month, that impairment occurs. Consistent with the WHO's ICF Checklist
rates and the CAPS-5, VA proposes to differentiate between impairment
occurring less than 25 percent of the time over the past month, and 25
percent of the time or more over the past month. The CAPS-5
distinguishes in its ratings between a frequency of ``some of the
time'' (20 to 30 percent) and more frequent occurrences. Weathers 2013,
supra. The WHO's ICF checklist, upon which the WHODAS 2.0 is based,
similarly distinguishes between impairments that are present less than
25 percent of the time and those occurring more than 25 percent of the
time in the past month. See ICF Checklist, pt. 2; see also Manual at 39
(``Recall abilities are most accurate for the period of one month.'').
Like other validated measures, VA recognizes that impairments that
occur 25 percent or more of the time present a greater impact on social
and occupational functioning than those that occur less frequently.
Consideration of both the intensity and frequency would yield the
level of impairment of functioning in each domain, and each level would
correlate to a numerical value, ranging from 0 to 4, which would be
defined as follows:
``0 = None''--``No difficulties;''
``1 = Mild impairment at any frequency; or moderate impairment
that occurs less than 25% of the time;''
``2 = Moderate impairment that occurs 25% or more of the time;
or severe impairment that occurs less than 25% of the time;''
``3 = Severe impairment that occurs 25% or more of the time; or
total impairment that occurs less than 25% of the time;'' and
``4 = Total impairment that occurs 25% or more of the time.''
C. Assigning a Disability Rating
Once an adjudicator determines the level of impairment of
functioning for each domain caused by a mental disorder, VA would
assign an evaluation of 10, 30, 50, 70, or 100 percent for the disorder
based upon the numerical value for each domain and the number of
domains affected. VA would assign the following ratings based upon the
following criteria:
----------------------------------------------------------------------------------------------------------------
Score
---------------------------------------------------------------------
Disability rating Level of impairment (0-
4) Number of affected domains
----------------------------------------------------------------------------------------------------------------
100....................................... 4 in 1 or more domains.
3 in 2 or more domains.
70........................................ 3 in 1 domain.
2 in 2 or more domains.
50........................................ 2 in 1 domain.
30........................................ 1 in 2 or more domains.
---------------------------------------------------------------------
10........................................ Minimum rating.
----------------------------------------------------------------------------------------------------------------
As reflected in this formula, veterans who have more severe
impairment in more domains will receive higher ratings. Veterans with
less severe impairment in less domains will receive lower ratings. But,
notably, a numerical value of 4 in just one domain will warrant a 100
percent rating; and a numerical value of 3 in just one domain will
warrant a 70 percent rating. This criterion should generally lead to
more generous compensation for veterans than the current rating
formula, which requires ``total occupational and social impairment''
for a 100 percent rating and ``deficiencies in most areas'' for a 70
percent rating. Moreover, VA proposes to eliminate the current rating
formula's provision for a noncompensable rating, and to provide a
minimum rating of 10 percent for all mental disorders. This is because
a disorder that meets the DSM-5 requirements for being a mental
disorder must include elements indicative of both harm and dysfunction.
Michael B. First et al., ``Diagnostic Criteria as Dysfunction
Indicators: Bridging the Chasm Between the Definition of Mental
Disorder and Diagnostic Criteria for Specific Disorders,'' 58 Canadian
J. of Psychiatry 663, 665 (Dec. 2013). Thus, a DSM-5 disorder will
rarely produce zero dysfunction. Id. Because the DSM-5 requirements
represent thresholds of minimal clinical confidence that a dysfunction
is present, VA will assign at least a 10 percent rating for such
disorders. Id. at 668.
IV. Elimination of Rating Formula for Eating Disorders
As previously noted, current Sec. 4.130 includes two separate
rating formulae for mental disorders--the General Rating Formula for
Mental Disorders and the Rating Formula For Eating Disorders. VA
created a separate Formula for Eating Disorders ``because their more
disabling aspects are manifested primarily by physical findings rather
than by psychological symptoms.'' 60 FR at 54829. The current Rating
Formula for Eating Disorders bases evaluations on the extent of weight
loss, incapacitating episodes, and required periods of hospitalization.
Id. However, in the DSM-5 at 339, the only eating disorder for which
weight is a diagnostic criterion is anorexia nervosa, and body mass
index (BMI) (weight in kilograms divided by height in meters squared
(kg/m\2\)) is used to specify the current severity of the disorder.
Weight and BMI are not diagnostic criteria in the DSM-5 for other
eating disorders, such as bulimia nervosa and binge-eating disorder,
nor are they specifiers for the severity of other eating disorders.
DSM-5 at 329-54.
As explained above, assessments like the WHODAS 2.0 can be used to
assess an individual's ability to perform life activities based upon
six areas of functioning as a result of any disorder, including eating
disorders. Liza H. Gold, ``DSM-5 and the Assessment of Functioning: The
World Health Organization Disability Assessment Schedule 2.0 (WHODAS
2.0),'' 42 J. Am
[[Page 8503]]
Acad. Psychiatry L. 173, 174-75 (2014). The test-retest reliability,
internal consistency, and concurrent validity of the WHODAS 2.0 in
comparison to other instruments for measuring disability has been
established in various patient populations and in general population
samples. Manual at 19-25. Based upon the diagnostic criteria and
severity specifiers for most eating disorders in the DSM-5 and the
universal applicability of the WHODAS 2.0, VA no longer sees a need for
a separate rating formula for eating disorders, and VA proposes to
instead evaluate the extent of disability caused by eating disorders
based upon the effect of an individual's disorder on the five domains
of functioning under the General Rating Formula for Mental Disorders
discussed above. VA seeks comment on this approach.
V. Proof-of-Concept Study
To derive the appropriate level to assign to each domain (e.g., 0
through 4), VA conducted a proof-of-concept study with 100 veterans
with service-connected mental disorders. Commonly known as feasibility
studies, proof-of-concept studies are designed to examine new methods
or treatments. The results of such studies improve the program or
evaluation procedure before using it on a larger scale. L. Thabane et
al., ``A tutorial on pilot studies: the what, why, and how,'' BMC
Medical Research Methodology 10:1, <a href="https://www.biomedcentral.com/content/pdf/1471-2288-10-1.pdf">https://www.biomedcentral.com/content/pdf/1471-2288-10-1.pdf</a> (last visited Nov. 19, 2019).
VA identified four specific aims of the proof-of-concept study to
examine the feasibility of the proposed rating criteria for mental
disorders. The first objective was to examine the distribution of
evaluations under the current and proposed rating criteria for mental
disorders. The second objective was to examine the extent to which the
revised Mental Disorders Disability Benefits Questionnaire (DBQ) would
adequately collect information needed to rate disabilities based upon
the proposed rating criteria. The third objective was to examine the
extent to which adjudicators were easily able to extract rating data
from the revised DBQ and apply the new evaluation criteria. The fourth
objective was to examine the extent to which Compensation and Pension
(C&P) examiners found the revised DBQ adequate and easy to use.
Regarding the first objective, the proof-of-concept study found
that the proposed General Rating Formula for Mental Disorders would
increase the average disability evaluation. Compared to the current
rating formula, fewer veterans would be rated at or below 50 percent
disability and more would be rated above 50 percent under the proposed
criteria. The two formulae seemed to yield similar results at 70
percent disabling, and the number of veterans who would receive 100
percent disability was greater under the proposed criteria than under
the current criteria.
Regarding the second objective, adjudicators reported that the
revised Mental Disorders DBQ provided all the information they needed
to evaluate based on the proposed criteria. Regarding the third
objective, adjudicators reported that they were easily able to extract
rating data from the revised DBQ and apply new evaluation criteria.
Finally, C&P examiners reported that the revised DBQ was adequate and
easy to use in a clinical setting.
Importantly, one major theme in the feedback regarding mental
disorders has been the need for a common language in the VASRD--a
language familiar to both clinicians and adjudicators. According to the
proof-of-concept study results, VA achieved this objective with the
proposed General Rating Formula for Mental Disorders.
VI. Notes to the Proposed General Rating Formula
VA proposes to add three notes at the end of the General Rating
Formula for Mental Disorders to promote greater consistency and
accuracy in applying the criteria.
The first note would provide that only one evaluation will be
assigned for co-existing service-connected mental disorders. According
to 38 U.S.C. 1155, the VA rating schedule shall compensate veterans for
``impairments of earning capacity,'' not specific diagnoses. And
according to 38 CFR 4.14, evaluations of the same disability or
manifestation under different diagnoses is to be avoided. Most mental
disorders are ``composed of multiple emotional, cognitive, and
behavioral dimensions, many of which are shared across disorders.'' Lee
Ann Clark et al., ``Three Approaches to Understanding and Classifying
Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental
Health's Research Domain Criteria (RDoC),'' 18 Psychol. Sci. in the
Pub. Int. 72, 112 (2017). In addition, co-existing mental disorders,
that is, comorbidity, ``is the rule rather than the exception.'' Id.
Therefore, consistent with 38 U.S.C. 1155 and the rule against
pyramiding, 38 CFR 4.14, Note (1) will instruct adjudicators not to
assign individual disability ratings to more than one mental disorder
given the likelihood of comorbid mental disorders and the prevalence of
overlapping symptoms among such disorders.
The second note would explain that evaluations under the General
Rating Formula for Mental Disorders would consider any ameliorating
effects of medications prescribed for a mental disorder. In other
words, if a veteran were receiving medication for a mental disability,
VA would rate only the disabling symptomatology that exists after the
ameliorative effects of medication are taken into account. We are
adding this note because in Jones v. Shinseki, 26 Vet. App. 56, 63
(2012), the United States Court of Appeals for Veterans Claims held
that, ``[a]bsent a clear statement [in the rating criteria] setting out
whether or how the Board [of Veterans' Appeals (Board)] should address
the effects of medication,'' the Board should not take those effects
into account when evaluating a claimant's disability. However,
consideration of ameliorating effects of medications is consistent with
38 CFR 4.2, which states that VA adjudicators should consider a
disability ``from the point of view of the veteran working or seeking
work'' and provide a current rating that ``accurately reflect[s] the
elements of disability present.'' VA adjudicators should not be basing
ratings on speculation of how severe a veteran's disability might be if
he or she were not taking medication; the rating should be based on the
actual elements of disability present. See generally McCarroll v.
McDonald, 28 Vet. App. 267, 276-78 (2016) (Kasold, J., concurring in
part).
The third note would explain that, in evaluating frequency, VA
adjudicators should consider the percentage of time, in a given month,
that impairment occurs. As discussed above, this is consistent with the
WHO's ICF Checklist rate. VA seeks comment on the three proposed notes.
VII. Technical Amendments
Finally, VA proposes to update Appendix A of part 4 to reflect the
above proposed amendments to the rating schedule for mental disorders.
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)
[[Page 8504]]
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
www.regulations.gov.
Regulatory Flexibility Act
The Secretary hereby certifies that this rulemaking 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 no small entities or
businesses would be subject to the rating criteria revisions or assign
evaluations for disability claims. 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 proposed rule contains no provisions constituting a collection
of information under the Paperwork Reduction Act of 1995 (44 U.S.C.
3501-3521).
Assistance Listing
The Assistance Listing 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 9, 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.
Michael P. Shores,
Director, Office of Regulation Policy & Management, Office of the
Secretary, Department of Veterans Affairs.
For the reasons set out in the preamble, VA proposes to amend 38
CFR part 4, subpart B as set forth below:
Part 4--SCHEDULE FOR RATING DISABILITIES
0
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
0
2. Amend Sec. 4.126 by:
0
a. Revising paragraph (a);
0
b. Removing paragraph (b); and
0
c. Redesignating paragraphs (c) and (d) as paragraphs (b) and (c).
The revisions read as follows:
Sec. 4.126 Evaluations of disability from mental disorders.
(a) When evaluating a mental disorder, the rating agency shall
consider all the evidence of record relevant to the intensity and
frequency of psychiatric symptoms that bear on the following domains
(major areas of functioning):
(1) Cognition (i.e., understanding and communicating);
(2) interpersonal interactions and relationships (i.e., interacting
with people and participating in society);
(3) task completion and life activities;
(4) navigating environments (i.e., getting around); and
(5) self-care.
The rating agency shall assess the intensity and frequency of
symptoms in each domain and assign an evaluation based on the combined
levels of functioning in these domains as explained in section 4.130.
* * * * *
0
3. Amend Sec. 4.130 by:
0
a. Republishing the entry for diagnostic code (DC) 9440;
0
b. Adding immediately following (DC) 9440, the entries for (DCs) 9520
and 9521;
0
c. Revising the table ``General Rating Formula for Mental Disorders'';
0
d. Removing immediately following the table ``General Rating Formula
for Mental Disorders'' the entries for (DCs) 9520 and 9521; and
0
e. Removing the table ``Rating Formula for Eating Disorders''.
The additions and revisions read as follows:
Sec. 4.130 Schedule of ratings--Mental disorders.
* * * * *
9440 Chronic adjustment disorder
9520 Anorexia nervosa
9521 Bulimia nervosa
General Rating Formula for Mental Disorders
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
The General Rating Formula for Mental Disorders contains
five domains related to function: Cognition;
interpersonal interactions and relationships; task
completion and life activities; navigating
environments; and self-care. The criteria below
describe each domain...................................
The General Rating Formula for Mental Disorders provides
criteria for each domain for levels of function ranging
from 0 to 4, as appropriate. The highest level of
impairment, a score of 4, signifies ``total,'' and the
lowest level of impairment, a score of 0, signifies
``no difficulties.''
Evaluate based on the level of impairment in each domain
and the number of affected domains, as follows:
Level 4 in one or more domains, or Level 3 in two or 100
more domains.......................................
Level 3 in one domain, or Level 2 in two or more 70
domains............................................
Level 2 in one domain............................... 50
Level 1 in two or more domains...................... 30
Minimum rating...................................... 10
------------------------------------------------------------------------
Note (1): Coexisting mental disorders cannot receive distinct and
separate disability evaluations without violating the anti-pyramiding
regulation of Sec. 4.14. Therefore, assign a single evaluation
reflecting all impairment due to coexisting service-connected mental
disorders using the General Rating Formula in this section.
Note (2): Include any ameliorating effects of medications when
evaluating the extent of disability under the General Rating Formula
in this section.
[[Page 8505]]
Note (3): In evaluating frequency of impairment, consider the percentage
of time, in a given month, that impairment occurs.
------------------------------------------------------------------------
Domain Level of impairment Criteria
------------------------------------------------------------------------
1. Cognition: May include, but is not limited to, memory, concentration,
attention, goal setting, speed of processing information, planning,
organizing, prioritizing, problem solving, judgment, making decisions,
or flexibility in adapting when appropriate.
------------------------------------------------------------------------
0 = None................ No difficulties:
Cognitive functioning
intact.
1 = Mild impairment at Mild: Slight
any frequency; or difficulties in one or
moderate impairment more aspects of
that occurs less than cognitive functioning
25% of the time. that do not interfere
with tasks, activities,
or relationships.
2 = Moderate impairment Moderate: Clinically
that occurs 25% or more significant
of the time; or severe difficulties in one or
impairment that occurs more aspects of
less than 25% of the cognitive functioning
time. that interfere with
tasks, activities, or
relationships.
3 = Severe impairment Severe: Serious
that occurs 25% or more difficulties in one or
of the time; or total more aspects of
impairment that occurs cognitive functioning
less than 25% of the that interfere with
time. tasks, activities, or
relationships.
4 = Total impairment Total: Profound
that occurs 25% or more difficulties in one or
of the time. more aspects of
cognitive functioning
that cannot be managed
or remediated;
incapable of even the
most basic tasks within
one or more aspects of
cognitive functioning;
difficulties that
completely interfere
with tasks, activities,
or relationships.
------------------------------------------------------------------------
2. Interpersonal interactions and relationships: Includes both informal
(social, associational, etc.) and formal (coworkers, supervisors, etc.).
------------------------------------------------------------------------
0 = None................ No difficulties:
Individual able to have
relationships and
interact with others at
work, school, and other
contexts.
1 = Mild impairment at Mild: Slight
any frequency; or difficulties in one or
moderate impairment more aspects of
that occurs less than interpersonal
25% of the time. functioning that do not
interfere with tasks,
activities, or
relationships.
2 = Moderate impairment Moderate: Clinically
that occurs 25% or more significant
of the time; or severe difficulties in one or
impairment that occurs more aspects of
less than 25% of the interpersonal
time. functioning that
interfere with tasks,
activities, or
relationships.
3 = Severe impairment Severe: Serious
that occurs 25% or more difficulties in one or
of the time; or total more aspects of
impairment that occurs interpersonal
less than 25% of the functioning that
time. interfere with tasks,
activities, or
relationships, even
with accommodations or
assistance.
4 = Total impairment Total: Profound
that occurs 25% or more difficulties in one or
of the time. more aspects of
interpersonal
functioning that cannot
be managed or
remediated; incapable
of even the most basic
tasks within one or
more aspects of
relationships;
difficulties that
completely interfere
with tasks, activities,
or relationships.
------------------------------------------------------------------------
3. Task completion and life activities: May include, but are not limited
to, the following types of activities: Vocational, educational,
domestic, social, or caregiving.
------------------------------------------------------------------------
0 = None................ No difficulties:
Individual able to
perform tasks and
participate in life
activities; needs no
accommodations or
assistance.
1 = Mild impairment at Mild: Slight
any frequency; or difficulties in one or
moderate impairment more aspects of task
that occurs less than completion or life
25% of the time. activities that were
completed with minor
stress or minor
accommodations.
2 = Moderate impairment Moderate: Clinically
that occurs 25% or more significant
of the time; or severe difficulties in one or
impairment that occurs more aspects of task
less than 25% of the completion or life
time. activities that were
completed with
significant stress or
accommodations.
3 = Severe impairment Severe: Serious
that occurs 25% or more difficulties in two or
of the time; or total more aspects of task
impairment that occurs completion or life
less than 25% of the activities that were
time. completed with
significant stress and
accommodations.
4 = Total impairment Total: Profound
that occurs 25% or more difficulties in two or
of the time. more aspects of task
completion or life
activities, one of
which must be
vocational, that were
not completed even with
considerable
accommodations due to
overwhelming stress;
incapable of even the
most basic tasks within
one or more aspects of
task completion or life
activities.
------------------------------------------------------------------------
4. Navigating environments: May include, but is not limited to, the
following: Leaving the home, being in confined or crowded spaces,
independently moving in surroundings, navigating new environments,
driving, or using public transportation.
------------------------------------------------------------------------
0 = None................ No difficulties:
Capability to navigate
environments intact.
1 = Mild impairment at Mild: Slight
any frequency; or difficulties in one or
moderate impairment more aspects of
that occurs less than navigating environments
25% of the time. that do not interfere
with tasks, activities,
or relationships.
2 = Moderate impairment Moderate: Clinically
that occurs 25% or more significant
of the time; or severe difficulties in one or
impairment that occurs more aspects of
less than 25% of the navigating environments
time. that interfere with
tasks, activities, or
relationships.
3 = Severe impairment Severe: Serious
that occurs 25% or more difficulties in one or
of the time; or total more areas of
impairment that occurs navigating environments
less than 25% of the that interfere with
time. tasks, activities, or
relationships, even
with accommodations or
assistance.
[[Page 8506]]
4 = Total impairment Total: Profound
that occurs 25% or more difficulties in one or
of the time. more aspects of
navigating environments
that cannot be managed
or remediated;
incapable of even the
most basic tasks within
one or more aspects of
environmental
navigation;
difficulties that
completely interfere
with tasks, activities,
or relationships.
------------------------------------------------------------------------
5. Self-care: May include, but is not limited to, the following types of
activities: Hygiene, dressing appropriately, or taking nourishment.
------------------------------------------------------------------------
0 = None................ No difficulties: Self-
care capabilities
intact.
1 = Mild impairment at Mild: Slight
any frequency; or difficulties in one or
moderate impairment more aspects of self-
that occurs less than care that do not
25% of the time. interfere with tasks,
activities, or
relationships.
2 = Moderate impairment Moderate: Clinically
that occurs 25% or more significant
of the time; or severe difficulties in one or
impairment that occurs more aspects of self-
less than 25% of the care that interfere
time. with tasks, activities,
or relationships
without accommodations
or assistance.
3 = Severe impairment Severe: Serious
that occurs 25% or more difficulties in one or
of the time; or total more aspects of self-
impairment that occurs care that interfere
less than 25% of the with tasks, activities,
time. or relationships, even
with accommodations or
assistance.
4 = Total impairment Total: Profound
that occurs 25% or more difficulties in one or
of the time. more aspects of self-
care that cannot be
managed or remediated;
difficulties that
completely interfere
with tasks, activities,
or relationships, even
with accommodations or
assistance.
------------------------------------------------------------------------
0
4. Amend Appendix A to part 4, Sec. 4.130, to read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946
------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------
* * * * * * *
4.130.......................... .............. Re-designated from Sec.
4.132 November 7,
1996; General Rating
Formula for Mental
Disorders revision
[Effective date of
final rule].
9520 Added November 7, 1996;
criterion [Effective
date of final rule].
9521 Added November 7, 1996;
criterion [Effective
date of final rule].
* * * * * * *
------------------------------------------------------------------------
(Authority: 38 U.S.C. 1155)
[FR Doc. 2022-02051 Filed 2-14-22; 8:45 am]
BILLING CODE 8320-01-P
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