[Federal Register Volume 76, Number 128 (Tuesday, July 5, 2011)]
[Proposed Rules]
[Pages 39160-39184]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-15698]
[[Page 39159]]
Vol. 76
Tuesday,
No. 128
July 5, 2011
Part II
Department of Veteran Affairs
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38 CFR Part 4
Schedule for Rating Disabilities; The Digestive System; Proposed Rule
Federal Register / Vol. 76 , No. 128 / Tuesday, July 5, 2011 /
Proposed Rules
[[Page 39160]]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AN12
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
portion of the Schedule for Rating Disabilities that addresses the
Digestive System. The purpose of this change is to incorporate medical
advances that have occurred since the last review, insert current
medical terminology, and provide clear criteria.
DATES: Comments must be received by VA on or before September 6, 2011.
ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand-delivery to the Director,
Regulations Management (02REG), Department of Veterans Affairs, 810
Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202)
273-9026. Comments should indicate that they are submitted in response
to RIN 2900-AN12-Schedule for Rating Disabilities; The Digestive
System. Copies of comments received will be available for public
inspection in the Office of Regulation Policy and Management, Room
1063B, between the hours of 8 a.m. and 4:30 p.m. Monday through Friday
(except holidays). Please call (202) 461-4902 for an appointment. (This
is not a toll-free number.) In addition, during the comment period,
comments may be viewed online through the Federal Docket Management
System at http://www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Thomas J. Kniffen, Chief, Regulations
Staff (211D), Compensation and Pension Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Avenue,
NW., Washington, DC 20420, (202) 461-9725. (This is not a toll-free
number.)
SUPPLEMENTARY INFORMATION: VA published an advance notice of proposed
rulemaking in the Federal Register of May 2, 1991 (56 FR 20168),
advising the public of our intent to revise and update the portion of
the Schedule for Rating Disabilities (the rating schedule) that
addresses the digestive system as well as to solicit and obtain
comments and suggestions from interest groups and the general public.
By revising the rating schedule, we aim to eliminate ambiguities,
include medical conditions not currently in the rating schedule, and
implement current medical criteria and terminology that reflect recent
medical advances.
Comments in Response To Advance Notice of Proposed Rulemaking
In response to the advance notice of proposed rulemaking, we
received comments from the American Legion and from several VA
employees. One commenter suggested that we add to the rating schedule
Crohn's disease; esophageal spasm (with its own evaluation criteria);
hepatitis A, B, and C; chronic inflammation of the liver and its
residuals; and malabsorption due to pancreatic disease. We propose to
address each of these conditions in this revision, except for hepatitis
and chronic inflammation of the liver, which were addressed in a
separate rulemaking on liver disabilities (66 FR 29486, May 31, 2001).
The same commenter suggested we include reflux esophagitis with
hiatal hernia, with the criteria taking into account a measurement of
reflux. For esophageal abnormalities, reflux measurement (manometry),
barium swallows, and esophagoscopy provide information about
physiological and anatomical abnormalities, and may be useful for
diagnosis and prognosis, for determining response to therapy, and to
prepare for surgery. They are less useful, however, in assessing the
level of disability than the severity of symptoms, the impact of the
condition on the nutritional status of the patient, and the potential
for remediation (``Disability Evaluation'' 379 (Stephen L. Demeter,
M.D., Gunnar B.J. Anderson, M.D., and George M. Smith, M.D., 1996) and
The Merck Manual 113 (18th ed. 2006)). While we propose to address
reflux esophagitis in this revision, as discussed further below, we do
not propose to use a measurement of reflux for evaluation.
A second commenter suggested we add Crohn's disease and also revise
the criteria for hemorrhoids. We propose to do both.
One commenter suggested that we evaluate gastrectomy and vagotomy-
pyloroplasty under the same criteria. The major postoperative problem
related to gastrectomy is dumping syndrome, which is the common term
that refers to the group of symptoms that may occur following various
types of surgery for ulcer disease. Many problems may be associated
with vagotomy-pyloroplasty, of which dumping syndrome is only one. We
therefore propose to retain separate evaluation criteria for these
conditions, as discussed in more detail below.
The same commenter suggested that we delete diagnostic codes 7201
(lips, injuries of), 7205 (esophagus, diverticulum of, acquired), 7306
(marginal ulcer), 7309 (stomach, stenosis of), 7310 (stomach, injury
of, residuals), 7315 (chronic cholelithiasis), 7316 (chronic
cholangitis), 7324 (distomiasis, intestinal or hepatic), and 7342
(visceroptosis) because they are rare.
We propose to remove diagnostic code 7342 (visceroptosis) because
visceroptosis is an obsolete diagnosis, as discussed further below.
However, we propose to retain all of the other diagnostic codes
mentioned by the commenter, although some in a revised form, since some
of them, such as diagnostic code 7315 (cholelithiasis), represent
common digestive diseases, and others, such as those for injuries of
the lips or stomach, may be the only appropriate codes under which to
address injuries, including combat wounds, to those parts of the body.
They may therefore be useful to VA for statistical purposes, as well as
for rating purposes.
Another commenter suggested we remove diagnostic code 7201 (lips,
injuries of); add esophagitis, duodenitis, and Crohn's disease; provide
a diagnostic code for total gastrectomy; add a 10-percent evaluation
level for cirrhosis; provide evaluation criteria for ileostomy and
colostomy; and provide objective evaluation criteria for pancreatitis.
We have already discussed injuries of the lips, which we propose to
retain. We otherwise propose to follow all of these suggestions, with
two exceptions. First, we do not propose to add a diagnostic code for
total gastrectomy, because that condition can be appropriately
evaluated under an existing diagnostic code (7308, Postgastrectomy
syndromes). Second, we have already added a 10-percent evaluation level
for cirrhosis in the separate rulemaking that addressed disabilities of
the liver (66 FR 29486, May 31, 2001), so there is no need for further
action in this proposed rule based on that comment. This commenter also
suggested we remove diagnostic codes 7342 (visceroptosis) and 7337
(pruritus ani) and that we delete the word ``infectious'' from
``infectious hepatitis.'' We also propose to remove diagnostic codes
7342 and 7337. The suggested change concerning hepatitis was made in
the separate rulemaking for liver disabilities, so there is no need for
further action in this proposed rule.
[[Page 39161]]
Outside Consultants
In addition to publishing an advance notice of proposed rulemaking,
VA contracted with an outside consulting firm for the purpose of
gathering suggestions for changes in the rating schedule to help
fulfill the goals of revising and updating the medical criteria. This
proposed amendment includes many of their suggestions. Since one of the
goals of the rating schedule revision is to eliminate ambiguities, we
did not follow some of our consultants' recommendations that are based,
at least, in part, on subjective or indefinite language when more
objective terminology could be used. Furthermore, each group of
consultants reviewed only one portion or body system of the rating
schedule, and we had to assess the feasibility of their recommendations
in light of the entire rating schedule, in order to assure internal
consistency. Relevant recommendations from our consultants are
discussed below.
Section 4.110
Current Sec. 4.110, ``Ulcers,'' explains that ``the term `peptic
ulcer' is not sufficiently specific for rating purposes'' because there
are ``manifest differences'' between ulcers of the stomach or duodenum
as compared to those at an anastomotic stoma, and that, therefore, the
location of an ulcer should be identified in order to evaluate it. This
material is unnecessary, since there are separate diagnostic codes for
ulcers of the stomach, duodenum, and gastrojejunal area (or anastomotic
stoma), and the rating schedule therefore makes it clear that the site
of an ulcer must be identified in order to assign the correct
diagnostic code. Furthermore, this section establishes no procedures
that raters must follow in evaluating ulcer disease. We therefore
propose to remove the material currently in Sec. 4.110, retitle this
section ``Dyspepsia,'' and provide in it a definition of the term
``dyspepsia'' for purposes of evaluating conditions in Sec. 4.114. We
propose that Sec. 4.110 would define dyspepsia as any combination of
the following symptoms: Gnawing or burning epigastric or substernal
pain that may be relieved by food (especially milk) or antacids,
nausea, vomiting, anorexia (lack or loss of appetite), abdominal
bloating, and belching. It would also state that when there is
obstruction of the outlet of the stomach (gastric outlet obstruction),
dyspepsia may also include symptoms of gastroesophageal reflux (flow of
stomach contents back into the esophagus), borborygmi (audible rumbling
bowel sounds), crampy pain, and obstipation (severe constipation).
Section 4.111
Current Sec. 4.111, ``Postgastrectomy syndromes,'' discusses
dumping syndrome, a condition which is relevant only to diagnostic code
7308, ``postgastrectomy syndromes,'' and we propose to list the
symptoms of dumping syndrome in a note under that diagnostic code. We
therefore propose to remove Sec. 4.111.
Section 4.112
Current Sec. 4.112, ``Weight loss,'' defines ``substantial weight
loss,'' ``minor weight loss,'' ``inability to gain weight,'' and
``baseline weight,'' for purposes of evaluating conditions in Sec.
4.114. Some of the revisions of conditions in Sec. 4.114 that we are
proposing have evaluation criteria that are based in part on
malnutrition, and there is no universally accepted definition of
malnutrition. We, therefore, propose to provide a definition of
malnutrition for purposes of evaluating conditions in Sec. 4.114 by
expanding the title of Sec. 4.112 to ``Weight loss and malnutrition''
and adding the following definition: `` `malnutrition' means a
deficiency state resulting from insufficient intake of one or multiple
essential nutrients or the inability of the body to absorb, utilize, or
retain such nutrients. It is characterized by failure of the body to
maintain normal organ functions and healthy tissues.''
Section 4.113
Current Sec. 4.113, ``Coexisting abdominal conditions,'' states
that there are diseases of the digestive system that produce a common
disability picture with similar symptoms and which should therefore not
be rated separately, as this would be a violation of 38 CFR 4.14,
``Avoidance of pyramiding'' (which states that the evaluation of the
same disability under various diagnoses is to be avoided). Current
Sec. 4.114, in an introductory paragraph, lists specific diagnostic
codes that cannot be combined, and directs that a single evaluation
``be assigned under the diagnostic code that reflects the predominant
disability picture, with elevation to the next higher evaluation where
the severity of the overall disability warrants such evaluation.'' In
order to provide clear guidance about evaluation when there are two or
more coexisting digestive conditions, we propose to revise the material
in Sec. Sec. 4.113 and 4.114 related to this subject and place the
revised directions in Sec. 4.113.
We propose to direct the rater to separately evaluate two or more
conditions in Sec. 4.114 only if the signs and symptoms attributed to
each are separable, and if they are not separable, to assign a single
evaluation under the diagnostic code that best allows evaluation of the
overall functional impairment resulting from both conditions. With
these instructions, the list of conditions that may not be combined,
given in current Sec. 4.114, would be unnecessary, and we propose to
remove it. This revision would provide a fair and equitable method of
evaluation, and is not contrary to Sec. 4.14. In addition, it would
remove the somewhat unclear direction to assign a diagnostic code that
reflects the predominant disability and elevate to the next higher
evaluation level ``where the severity of the overall disability
warrants such elevation,'' a direction that could be interpreted
differently by different individuals. We also propose to change the
title of Sec. 4.113 to ``Evaluation of coexisting digestive
conditions,'' since not all disabilities in this body system are
abdominal, as the current title of Sec. 4.113 implies.
Section 4.114 Schedule of Ratings-Digestive System
Mouth injuries, Lip injuries, Tongue Injuries (Including Tongue Loss),
Esophageal Stricture, Achalasia (Cardiospasm) and Other Motor Disorders
of the Esophagus, and Esophageal Diverticula (Diagnostic Codes 7200-
7205)
The current rating schedule directs that injuries of the mouth
(diagnostic code 7200) be evaluated on the basis of disfigurement and
impairment of masticatory function, and injuries of the lips
(diagnostic code 7201) on the basis of disfigurement of the face. Both
mouth and lip injuries are therefore evaluated using criteria under
other diagnostic codes. Loss of whole or part of the tongue (diagnostic
code 7202) is currently evaluated at 100 percent if there is inability
to communicate by speech, at 60 percent if there is loss of one-half or
more of the tongue, and at 30 percent if there is marked speech
impairment. Findings in these three conditions sometimes overlap,
according to our consultants, with the major problems being (1)
Difficulty with mastication (chewing) or swallowing, causing a
restriction of diet; (2) difficulty with speech; (3) loss of part of
the tongue; and (4) disfigurement. We therefore propose to provide a
general rating formula for the evaluation of residuals of mouth
injuries, lip injuries,
[[Page 39162]]
and tongue injuries, including tongue loss.
In addition, there are several esophageal abnormalities with signs
and symptoms that are similar to one another, and that also overlap the
findings in mouth, lip, and tongue injuries. For these reasons, we
propose to include several esophageal conditions in the same general
rating formula for this whole group of conditions, as discussed in more
detail below. Our consultants recommended that there be a 10-percent
evaluation level for each of these disabilities, and also pointed out
that stricture of the esophagus, for example, can be totally disabling.
We agree, and propose to provide evaluation levels of 100, 60, 30, and
10 percent in this general rating formula.
Stricture of the esophagus (diagnostic code 7203) is currently
evaluated at 80 percent if it permits ``passage of liquids only, with
marked impairment of general health;'' at 50 percent if it is ``severe,
permitting liquids only;'' and at 30 percent if it is ``moderate.''
These criteria contain subjective terms such as ``marked,''
``moderate,'' and ``severe,'' which could be interpreted differently by
different individuals. The general rating formula we are proposing for
the evaluation of this and other related conditions with symptoms in
common would provide more objective criteria.
Spasm of the esophagus (cardiospasm) (diagnostic code 7204) is
currently evaluated based on the degree of obstruction (stricture), if
not amenable to dilation. We propose to update the title of diagnostic
code 7204 from ``cardiospasm'' to ``achalasia,'' the current term for
this condition. Achalasia is a condition in which, upon swallowing,
there is a failure of relaxation of the lower esophageal sphincter (at
the junction of the esophagus and stomach). We also propose to include
in this diagnostic code other related motor disorders of the esophagus
with impairment in the normal passage of food through the esophagus due
to muscle or nerve abnormalities, by revising the title to ``Achalasia
(cardiospasm) and other motor disorders of the esophagus (diffuse
esophageal spasm, corkscrew esophagus, nutcracker esophagus, etc.).''
Our consultants suggested we provide one diagnostic code for achalasia,
with 100- and 30-percent evaluation levels, and another for other
esophageal motor disorders, with 50-, 30-, and 10-percent evaluation
levels. However, the signs and symptoms of these conditions are very
similar, and the severity of disability from any one of these
conditions varies widely from individual to individual. Therefore, in
our judgment, it is feasible and preferable to provide a single
diagnostic code with a broad range of evaluations (100 to 10 percent),
for the sake of promoting more consistent and appropriate evaluations.
Acquired diverticulum of the esophagus (diagnostic code 7205) is
currently evaluated as obstruction (stricture). We propose to revise
the title of diagnostic code 7205 from ``Esophagus, diverticulum of''
to ``Esophageal diverticula, including pharyngoesophageal (Zenker's),
midesophageal, and epiphrenic types'' to indicate more clearly the
several types of diverticula that may warrant evaluation under this
diagnostic code. Achalasia and esophageal diverticulum result in
impairments similar to one another, and there is overlap with
impairments resulting from mouth, lip, and tongue injuries. In
addition, esophageal stricture, achalasia, and esophageal diverticulum
may all result in pulmonary aspiration (inhaling food or liquid into
the lungs) due to regurgitation or vomiting and may require treatment
with prescription medication to control symptoms. Esophageal dilation
may be required for stricture or achalasia. We therefore propose to
include criteria for these esophageal conditions, as well as mouth,
lip, and tongue injuries, in a general rating formula that encompasses
the main signs and symptoms of all.
We propose to title the general rating formula for this group of
conditions as follows: ``General Rating Formula for Residuals of mouth
injuries (diagnostic code 7200), Residuals of lip injuries (diagnostic
code 7201), Residuals of tongue injuries, including tongue loss
(diagnostic code 7202), Esophageal stricture (diagnostic code 7203),
Achalasia (cardiospasm) and other motor disorders of the esophagus
(diagnostic code 7204), and Esophageal diverticula (diagnostic code
7205).'' We propose to base evaluation of these conditions on the
extent of limitation of diet, on the extent of the ability to speak
clearly enough to be understood, on the frequency of episodes of
pulmonary aspiration due to regurgitation or vomiting, and on whether
or not continuous treatment with prescription medication is required.
We propose to provide a list of findings at each evaluation level, any
of which would warrant that percentage of evaluation.
We propose a 100-percent evaluation for any of the following: Tube
feeding required; diet restricted to liquid foods, with substantial
weight loss, malnutrition, and anemia; four or more episodes per year
of pulmonary aspiration (with bronchitis, pneumonia, or pulmonary
abscess) due to regurgitation or vomiting; or inability to speak
clearly enough to be understood. We propose a 60-percent evaluation for
any of the following: Diet restricted to liquid and soft solid foods,
with substantial weight loss or anemia; two to three episodes per year
of pulmonary aspiration (with bronchitis, pneumonia, or pulmonary
abscess) due to regurgitation or vomiting; or inability to speak
clearly enough to be understood at least half of the time but not all
of the time. We propose a 30-percent evaluation for any of the
following: Diet restricted to liquid and soft solid foods, with minor
weight loss; esophageal dilation carried out five or more times per
year; daily regurgitation or vomiting; one episode per year of
pulmonary aspiration (with bronchitis, pneumonia, or pulmonary abscess)
due to regurgitation or vomiting; or inability to speak clearly enough
to be understood at times, but less than half of the time. We propose a
10-percent evaluation for any of the following: Diet restricted to
liquid and soft solid foods; esophageal dilation carried out one to
four times per year; heartburn (pyrosis) requiring continous treatment
with prescription and at least one of the following other symptoms:
Retrosternal chest pain, difficulty swallowing (dysphagia), or pain
during swallowing (odynophagia); partial tongue loss; or impaired
articulation for some words, but speech understandable.
We also propose to add a note directing raters to separately
evaluate mouth and lip injuries under diagnostic code 7800 (Burn
scar(s) of the head, face, or neck; scar(s) of the head, face, or neck
due to other causes; or other disfigurement of the head, face, or
neck), if applicable, and to combine this with an evaluation under this
general rating formula, under the provisions of Sec. 4.25.
The proposed general rating formula for these conditions is broad
enough to encompass any degree of severity of the major types of
impairment from any of these conditions, and from combined injuries of
more than one of these structures. It also provides more objective
criteria than the current schedule because it excludes subjective
descriptors like ``marked'' and more sharply defines the extent of
speech impairment and dietary limitations required for various
evaluations. Evaluations should, therefore, be more consistent.
Although our consultants used subjective terms such as ``moderate'' and
``severe'' in their recommended criteria, we are proposing to exclude
such terms whenever possible throughout the revision of the
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rating schedule, for the sake of promoting consistent evaluations. Our
consultants also included the nebulous phrase ``interfering with normal
daily functioning,'' which could be subject to different
interpretations by different people, and we do not propose to use this
language. However, the criteria are otherwise substantially the same as
those our consultants recommended.
Salivary Gland Disease (Diagnostic Code 7207)
Since there is no current diagnostic code under which salivary
gland disease can be appropriately evaluated, and it is a common enough
disability in veterans to require evaluation, we propose to add
diagnostic code 7207, ``Salivary gland (parotid, submandibular,
sublingual) disease other than neoplasm.'' We propose that there be 20-
, 10-, and zero-percent evaluation levels, based on the presence of
xerostomia (dry mouth) and its effects, chronic inflammation or
swelling of a salivary gland, salivary gland calculi or stricture,
increase in dental caries, and weight loss, because these are the major
impairments that may result from salivary gland disease (``Textbook of
Gastroenterology'' 225 (Tadataka Yamada, M.D., ed., 1991)).
We propose a 20-percent evaluation for xerostomia (dry mouth) with
altered sensation of taste and difficulty with lubrication and
mastication of food resulting in either weight loss or increase in
dental caries; a 10-percent evaluation for xerostomia with altered
sensation of taste and difficulty with lubrication and mastication of
food, but without weight loss or increase in dental caries; chronic
inflammation of a salivary gland with pain and swelling on eating; one
or more salivary calculi; or a salivary gland stricture. We propose a
zero-percent evaluation for either xerostomia without difficulty in
mastication of food, or painless swelling of the salivary gland. We are
proposing a zero-percent evaluation level in order to make it clear
that these findings warrant a zero-, rather than a ten-percent
evaluation when it might otherwise be unclear to the rater.
We also propose to provide note (1) directing that facial nerve
(cranial nerve VII) impairment, which may result from parotid gland
disease or its treatment, be evaluated under diagnostic code 8207
(cranial nerve VII) and that any disfigurement due to facial swelling
be evaluated under diagnostic code (Burn scar(s) of the head, face, or
neck; scar(s) of the head, face, or neck due to other causes; or other
disfigurement of the head, face, or neck). We propose to add note (2)
to explain what Sjogren's syndrome is and how it should be evaluated.
It is an autoimmune disorder that causes xerostomia (dry mouth) and
keratoconjunctivitis sicca (dry eyes) and may affect other parts of the
body. The note directs that the effects of xerostomia (dry mouth) due
to Sjogren's syndrome be evaluated under diagnostic code 7207,
keratoconjunctivitis sicca under the portion of the rating schedule
that addresses Organs of Special Sense, and other effects of the
syndrome, if any, on other body parts under appropriate diagnostic
codes in other sections of the rating schedule.
Peritoneal Adhesions (Diagnostic Code 7301)
Peritoneal adhesions, diagnostic code 7301, are currently evaluated
at levels of 50, 30, 10, or zero percent. A 50-percent evaluation is
assigned if adhesions are severe, with ``definite partial obstruction
shown by X-ray, with frequent and prolonged episodes of severe colic
distention, nausea or vomiting, following severe peritonitis, ruptured
appendix, perforated ulcer, or operation with drainage.'' A 30-percent
evaluation is assigned if adhesions are moderately severe, with
``partial obstruction manifested by delayed motility of barium meal and
less frequent and less prolonged episodes of pain.'' A 10-percent
evaluation is assigned if adhesions are moderate, with ``pulling pain
on attempting work or aggravated by movements of the body, or
occasional episodes of colic pain, nausea, constipation (perhaps
alternating with diarrhea) or abdominal distention.'' A zero-percent
evaluation is assigned if adhesions are ``mild.'' Subjective adjectives
such as ``mild,'' ``moderate,'' ``moderately severe,'' and ``severe''
are used at each level.
We propose to provide evaluation levels of 60, 30, or 10 percent
for peritoneal adhesions, based primarily on the number of episodes of
partial intestinal obstruction with typical symptoms, which may
include, but are not limited to colicky abdominal pain, abdominal
distention, borborygmi (audible rumbling bowel sounds), nausea,
vomiting, and obstipation (severe constipation) (Yamada, 719). X-ray
confirmation of a partial bowel obstruction would be required for any
level of evaluation.
We propose a 60-percent evaluation for six or more episodes per
year of partial obstruction of the bowel (confirmed by X-ray), with
typical signs and symptoms (which may include, but are not limited to
colicky abdominal pain, abdominal distention, borborygmi (audible
rumbling bowel sounds), nausea, vomiting, and obstipation) (severe
constipation)); a 30-percent evaluation for three to five episodes per
year of partial obstruction of the bowel, with typical signs and
symptoms; and a 10-percent evaluation for either of the following: One
or two episodes per year of partial obstruction of the bowel, with
typical signs and symptoms, or, in the absence of such episodes,
pulling pain on body movement, if not attributable to another
condition.
These criteria are in general agreement with those recommended by
our consultants, but they exclude subjective terms such as
``frequent,'' ``occasional,'' and ``severe'' that the consultants
suggested, in favor of more objective criteria in order to promote
consistent evaluations.
A current note following diagnostic code 7301 states that ratings
for adhesions will be considered when there is a history of operative
or other traumatic or infectious (intraabdominal) process and at least
two of the following: Disturbance of motility, actual partial
obstruction, reflex disturbances, or presence of pain. We propose to
revise this note to state that evaluation under diagnostic code 7301
requires a history of abdominal or pelvic surgery, infection,
irradiation, trauma, or other known etiology for peritoneal adhesions.
We propose to add a second note listing the typical signs and symptoms
of partial bowel obstruction, for purposes of evaluation under
diagnostic code 7301. This would simplify the evaluation criteria by
eliminating the need to repeat the list of symptoms at each level. Our
consultants recommended that we provide a note similar to the current
note, with both causes and symptoms of adhesions listed, and we have
basically done this, but divided the material into two notes, for the
sake of clarity.
General Rating Formula for Ulcer Disease (Diagnostic Codes 7304-7306)
There are currently three diagnostic codes for ulcers: diagnostic
code 7304 for gastric ulcers, diagnostic code 7305 for duodenal ulcers,
and diagnostic code 7306 for marginal (gastrojejunal) ulcers. No
specific evaluation criteria are provided for gastric ulcers, but they
are ordinarily rated under the criteria for duodenal ulcers. Duodenal
ulcers are currently evaluated at levels of 60, 40, 20, or 10 percent.
A 60-percent evaluation is assigned if the condition is severe, with
pain only partially relieved by ulcer therapy, and there is periodic
vomiting, recurrent hematemesis or melena, with manifestations of
anemia and weight loss, productive of definite impairment of health. A
40-percent evaluation is assigned if the condition is moderately
severe, meaning that it is
[[Page 39164]]
less than severe but with impairment of health manifested by anemia and
weight loss, or that there are recurrent incapacitating episodes
averaging 10 days or more in duration at least four or more times a
year. A 20-percent evaluation is assigned if the condition is moderate,
with recurring episodes of severe symptoms two or three times a year
averaging 10 days in duration, or with continuous moderate
manifestations. A 10-percent evaluation is assigned if the condition is
mild, with recurring symptoms once or twice yearly.
Marginal ulcers are currently evaluated under a separate set of
criteria that are similar to those for duodenal ulcer, except that
there is also a 100-percent evaluation level, to be assigned if the
condition is pronounced, with periodic or continuous pain unrelieved by
standard ulcer therapy with periodic vomiting, recurring melena or
hematemesis, and weight loss, and the condition is totally
incapacitating. A 60-percent evaluation is assigned if the condition is
severe, with symptoms of the same type as pronounced but less
pronounced and less continuous, with definite impairment of health. A
40-percent evaluation is assigned if the condition is moderately
severe, with intercurrent episodes of abdominal pain at least once a
month partially or completely relieved by ulcer therapy, or there are
mild and transient episodes of vomiting or melena. A 20-percent
evaluation is assigned if the condition is moderate, with episodes of
recurring symptoms several times a year. A 10-percent evaluation is
assigned if the condition is mild, with brief episodes of recurring
symptoms once or twice yearly. Both sets of criteria for rating ulcer
disease use subjective adjectives such as ``mild,'' ``moderate,'' and
``pronounced'' throughout the formulas.
Our consultants pointed out that while ulcers may vary in location,
they produce the same array of symptoms, and do not differ in
functional impairment. They suggested that all types of ulcers be
evaluated under the same criteria: the presence of symptoms and their
response or lack of response to treatment, the extent of incapacitating
or recurring episodes, and whether there is recurrent hematemesis
(vomiting blood) or melena, anemia, or weight loss. We propose to
adopt, with some modifications, their recommendations regarding bases
of evaluations and to evaluate all types of ulcer disease under the
same criteria. We propose to provide a single rating formula for
gastric ulcer (diagnostic code 7304), duodenal ulcer (diagnostic code
7305), and marginal (gastrojejunal) ulcer (diagnostic code 7306), based
on the recommended criteria. We also propose to change the title of
diagnostic code 7305 to ``duodenal ulcer or duodenitis'' in order to
include duodenitis under this code, because these conditions commonly
occur together and result in similar findings. We propose to provide
evaluation levels of 100, 60, 30, and 10 percent. Our consultants
suggested 60 percent as the highest level of evaluation, but, because
our experience has shown that a number of veterans are totally disabled
by severe ulcer disease, we propose to add a 100-percent level. These
levels also differ from the current schedule by substituting a 30-
percent level for the current 20- and 40-percent levels. This change
will provide a clearer distinction between the 10-percent level and the
next higher level (which we propose to be 30 percent instead of 20
percent), a factor that will promote more consistent evaluations, and
will still be sufficient to accommodate the range of severity of ulcer
disease.
We propose a 100-percent evaluation for either substantial weight
loss, malnutrition, and anemia due to gastrointestinal bleeding; or for
hospitalization three or more times per year for vomiting, refractory
pain, gastrointestinal bleeding, perforation, obstruction, or
penetration to liver, pancreas, or colon. We propose a 60-percent
evaluation for either periodic or constant dyspepsia with substantial
weight loss and anemia due to ulcer disease; or for hospitalization two
times per year for vomiting, refractory pain, gastrointestinal
bleeding, perforation, obstruction, or penetration to liver, pancreas,
or colon. We propose a 30-percent evaluation for either periodic or
constant dyspepsia with at least minor weight loss; or for
hospitalization once per year for vomiting, refractory pain,
gastrointestinal bleeding, perforation, obstruction, or penetration to
liver, pancreas, or colon. We propose a 10-percent evaluation for
recurring dyspepsia that requires continuous treatment with
prescription medication for control.
We also propose to add a note under the general rating formula for
ulcer disease stating that the diagnosis of ulcer disease or duodenitis
requires confirmation on at least one occasion by imaging or endoscopy.
Because the symptoms of ulcer disease are not specific, the note would
assure that the diagnosis of ulcer disease is not based on symptoms
alone.
Chronic Gastritis (Diagnostic Code 7307)
We propose to revise the title of diagnostic code 7307 from the
current ``gastritis, hypertrophic (identified by gastroscope)'' to
``chronic gastritis (including but not limited to erosive,
hypertrophic, hemorrhagic, bile reflux, alcoholic, and drug-induced
gastritis)'' to indicate that there are several types of gastritis that
may be evaluated under this code.
Gastritis is an inflammation of the gastric (stomach) mucosa.
Common causes include Helicobacter pylori infection, non-steroidal
anti-inflammatory drugs, alcohol, stress, and autoimmune phenomena
(atrophic gastritis) (Merck, 117). While chronic gastritis is often
asymptomatic (symptom-free), it may cause dyspepsia and sometimes
gastro-intestinal bleeding with resulting anemia. A rare type of
gastritis results in protein-losing gastropathy (disease of the
stomach), in which hypoalbuminia (low albumin level in blood),
diarrhea, weight loss, and edema may occur. Gastritis is currently
evaluated at 60, 30, or 10 percent, with a 60-percent evaluation
assigned when the condition is chronic, with severe hemorrhages or
large ulcerated or eroded areas; a 30-percent evaluation when the
condition is chronic, ``with multiple small eroded or ulcerated areas,
and symptoms;'' and a 10-percent evaluation when the condition is
chronic, ``with small nodular lesions, and symptoms.'' We propose to
continue these evaluation levels, but to provide different criteria,
based more on objective clinical findings, which are common indicators
of disability, than on the pathologic appearance of the gastric mucosa.
We propose a 60-percent evaluation for any of the following:
Periodic or continuous dyspepsia with anemia due to gastrointestinal
bleeding; protein-losing gastropathy with substantial weight loss and
peripheral edema; or hospitalization two or more times per year for
gastrointestinal bleeding, intractable vomiting, or other complication
of chronic gastritis. We propose a 30-percent evaluation for either of
the following: Protein-losing gastropathy with at least minor weight
loss, or hospitalization once per year for gastrointestinal bleeding,
intractable vomiting, or other complication of chronic gastritis. We
propose a 10-percent evaluation for dyspepsia that requires continuous
treatment with prescription medication.
These proposed criteria are similar to those recommended by our
consultants, but have been modified to remove
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subjective terms, and for the sake of internal consistency. In order to
document that gastritis, which is often hard to diagnose, is definitely
present, we also propose to add a note stating that evaluation under
diagnostic code 7307 requires that the diagnosis of chronic gastritis
be confirmed on at least one occasion by endoscopy. The condition of
``gastritis, atrophic'' is listed in the current schedule at the end of
the criteria for hypertrophic gastritis. It is followed by a statement
that this is ``a complication of a number of diseases, including
pernicious anemia,'' and a direction to rate the underlying condition.
We propose to include this information in a second note under
diagnostic code 7307, to provide clear guidance to the raters on how to
evaluate atrophic gastritis.
Postgastrectomy Syndromes (Diagnostic Code 7308)
Postgastrectomy syndromes (diagnostic code 7308) are currently
evaluated at levels of 60, 40, or 20 percent, based on frequency of
episodes of symptoms. A 60-percent evaluation is assigned when the
condition is severe, meaning that it is associated with nausea,
sweating, circulatory disturbance after meals, diarrhea, hypoglycemic
symptoms, and weight loss with malnutrition and anemia; a 40-percent
evaluation when the condition is moderate, with less frequent episodes
of epigastric disorders with characteristic mild circulatory symptoms
after meals but with diarrhea and weight loss; and a 20-percent
evaluation when the condition is mild, with infrequent episodes of
epigastric distress with characteristic mild circulatory symptoms or
continuous mild manifestations.
We propose to base evaluations of postgastrectomy syndromes on more
objective criteria, such as the frequency of dumping syndrome (which is
the common term for the group of symptoms that may occur following
various types of surgery for ulcer disease), whether there is weight
loss, malnutrition or anemia, and whether a restricted diet is needed.
For the sake of simplicity, we propose to list the possible signs and
symptoms of postgastrectomy syndromes in a note rather than listing all
possible manifestations at every evaluation level.
Several types of problems may occur after gastrectomy, with the
onset, frequency, and types of symptoms varying with the particular
type of surgery performed (Merck, 123). One problem is the dumping
syndrome. There are two types of dumping syndrome, an early type that
occurs within 30 minutes of eating, and a late type that occurs 90
minutes to 3 hours after eating (``Harrison's Principles of Internal
Medicine'' 1240 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)).
Although early and late types have different causes, their symptoms
overlap. Rather than experiencing a dumping syndrome, some individuals
experience only severe diarrhea as a major postgastrectomy problem.
Others experience abdominal pain, bilious vomiting (vomiting of bile),
anemia, and weight loss due to a condition called alkaline reflux
gastritis (also called biliary gastritis or bile reflux gastritis); and
some individuals have malabsorption and poor absorption of vitamins and
minerals resulting in malnutrition and anemia as their most significant
problems (Yamada, 1394).
Since the signs and symptoms of these postgastrectomy syndromes
overlap, and ``dumping syndrome'' is the commonly used designation for
postgastrectomy signs and symptoms, we propose to lump the various
postgastrectomy syndromes together as ``dumping syndrome'' and to add a
note under diagnostic code 7308 stating that for purposes of evaluation
under diagnostic code 7308, the term ``dumping syndrome'' includes
symptoms that are associated with any of the following postgastrectomy
syndromes: Early and late types of dumping syndrome, postgastrectomy
diarrhea, and alkaline reflux gastritis. These symptoms include any
combination of weakness, dizziness, lightheadedness, diaphoresis
(sweating), palpitations, tachycardia, postural hypotension, confusion,
syncope (fainting), nausea, vomiting (often with bile), diarrhea,
steatorrhea (fatty stools), borborygmi (audible rumbling bowel sounds),
abdominal pain, anorexia (lack or loss of appetite), abdominal
bloating, and belching. In order to include both types of
postgastrectomy dumping syndromes, we also propose to state, in the
same note, that symptoms may occur immediately after eating or up to
three hours later.
We propose to provide evaluation levels of 100, 60, 30, and 10
percent, instead of the current 60, 40, and 20 percent. Our consultants
suggested that we add a 100-percent evaluation level, since
postgastrectomy syndromes may be severely disabling, and we propose to
do so. As with gastritis, to promote consistent evaluations, we propose
to substitute a 30-percent evaluation level for the 20- and 40-percent
levels to provide a clearer distinction between adjacent levels. We
also propose to add a 10-percent evaluation level for milder cases of
dumping syndrome. We propose a 100-percent evaluation for dumping
syndrome that occurs after most meals, with substantial weight loss,
malnutrition, and anemia. We propose a 60-percent evaluation for
dumping syndrome that occurs after most meals, with substantial weight
loss and anemia. We propose a 30-percent evaluation for dumping
syndrome that occurs daily or nearly so, despite treatment, with at
least minor weight loss. We propose a 10-percent evaluation for
intermittent dumping syndrome (occurring at least three times a week)
requiring dietary restrictions.
Our consultants suggested criteria that retain the same subjective
terms of ``infrequent,'' ``mild,'' and ``less frequent,'' as the
current schedule. For example, our consultants recommended that a 20-
percent evaluation be assigned for post-gastrectomy syndrome that is
``mild'' with ``infrequent'' episodes of epigastric distress with
``characteristic mild'' circulatory symptoms or continuous ``mild''
manifestations. We propose to use more specific terms such as ``after
most meals'' and ``daily or nearly so,'' since making the criteria less
ambiguous is one of the goals of the revision of the rating schedule.
In order to make the criteria clear to everyone who uses the rating
schedule, we propose to list the actual symptoms (many of which
overlap) of hypoglycemia and circulatory disturbance in the note
defining dumping syndrome, rather than use less clear terms such as
``hypoglycemic symptoms'' or ``circulatory symptoms,'' as the
consultants suggested. We also propose a second note to direct raters
to separately evaluate complications, such as osteomalacia, under an
appropriate diagnostic code.
Gastric Emptying Disorders (Diagnostic Code 7309)
Diagnostic code 7309 is currently titled ``stomach, stenosis of''
and includes an instruction to ``[r]ate as for gastric ulcer''
(diagnostic code 7304), which in turn is usually rated as duodenal
ulcer (diagnostic code 7305). We propose to make diagnostic code 7309
more inclusive by changing the title to ``gastric emptying disorders
(including gastroparesis (delayed gastric emptying), and pyloric,
gastric, and other motility disturbances)'' because all of these
conditions, which are not uncommon and are not currently listed in the
current rating schedule, may produce similar signs and symptoms.
We propose to provide evaluation levels of 100, 60, 30, and 10
percent for diagnostic code 7309. As our consultants pointed out, these
conditions can be very debilitating. We
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propose to base the evaluation on criteria specific to gastric emptying
disorders--epigastric pain or fullness, anorexia (lack or loss of
appetite), nausea, vomiting, gastroesophageal reflux, early satiety
(feeling that hunger and thirst are satisfied), and abdominal bloating
(Yamada, 1264). We propose to add a note listing the signs and symptoms
of gastric emptying disorders, for purposes of evaluation under
diagnostic code 7309.
We propose a 100-percent evaluation for daily or near-daily signs
and symptoms with substantial weight loss and malnutrition. We propose
a 60-percent evaluation for periodic or daily or near-daily signs and
symptoms with substantial weight loss. We propose a 30-percent
evaluation for periodic signs and symptoms with minor weight loss. We
propose a 10-percent evaluation for periodic signs and symptoms without
weight loss, but requiring continuous treatment with prescription
medication. These criteria are specific to the disability and are
clearer and more objective than those proposed by our consultants.
While the consultants used similar symptoms, they also included
modifiers like ``pronounced,'' ``severe,'' and ``moderate,'' which are
subjective terms that we are trying to exclude from the rating schedule
when possible, for the sake of consistent evaluations.
Injury of the Stomach (Diagnostic Code 7310)
Injury of the stomach, diagnostic code 7310, is currently evaluated
under the criteria for peritoneal adhesions (diagnostic code 7301). We
propose to retain that direction and to add an alternative direction,
as recommended by our consultants, to evaluate as postgastrectomy
syndromes (diagnostic code 7308) if the injury required a gastric
resection.
Liver Disease
In a separate rulemaking, we previously revised the portion of
Sec. 4.114 that addresses liver disease, including injury of the liver
(diagnostic code 7311), cirrhosis of the liver (diagnostic code 7312),
deletion of residuals of abscess of liver (diagnostic code 7313),
infectious hepatitis (diagnostic code 7345), benign new growths of the
digestive system (7344), and malignant new growths of the digestive
system, exclusive of skin growths (diagnostic code 7343). Following
notice and comment, this rulemaking was published as a final rule on
May 31, 2001 (66 FR 29486). We do not propose any further changes to
those diagnostic codes.
Biliary Tract Disease or Injury (Diagnostic Code 7314)
Diagnostic code 7314 is currently titled ``cholecystitis, chronic''
and has evaluation levels of 30, 10, and zero percent. A 30-percent
evaluation is assigned if the condition is severe, with frequent
attacks of gall bladder colic; a 10-percent evaluation if the condition
is moderate, with gall bladder dyspepsia, confirmed by X-ray technique,
and with infrequent attacks (not over two or three a year) of gall
bladder colic, with or without jaundice; and a zero-percent evaluation
if the condition is mild.
Chronic cholelithiasis (diagnostic code 7315) and chronic
cholangitis (diagnostic code 7316) are evaluated under the same
criteria as chronic cholecystitis. All of these conditions are closely
related and may co-exist, and can readily be evaluated under a single
diagnostic code and set of evaluation criteria. In addition, diagnostic
code 7318, ``Gall bladder, removal of,'' can result in signs and
symptoms similar to those of the above three conditions. It is
currently evaluated at 30, 10, or zero percent, under subjectively-
defined criteria. A 30-percent evaluation is assigned if there are
``severe symptoms,'' a 10-percent evaluation if there are ``mild
symptoms,'' and a zero-percent evaluation if the condition is
nonsymptomatic. ``Gall bladder, injury of'' (diagnostic code 7317) is
currently rated as peritoneal adhesions.
We, therefore, propose to revise the title of diagnostic code 7314
to the more inclusive ``Biliary tract disease or injury (chronic
cholecystitis, cholelithiasis, choledocholithiasis, chronic
cholangitis, status post-cholecystectomy, gall bladder or bile duct
injury, biliary dyskinesia, cholesterolosis, polyps of gall bladder,
sclerosing cholangitis, stricture or infection of the bile ducts,
choledochal cyst)'' because all of these conditions are related and may
produce similar effects. It is therefore appropriate to evaluate them
under the same criteria. It is not uncommon for more than one of these
conditions to be present at the same time, and using a single set of
criteria would better allow an appropriate overall evaluation in those
cases, since the signs and symptoms overlap and may be identical. Our
consultants did not suggest combining these conditions under a single
diagnostic code, as we are proposing, but did suggest evaluating them
under the same criteria. The evaluation criteria we are proposing are
similar to those they suggested, but would eliminate the subjective
terms ``severe,'' ``moderate'' and ``mild''.
Although the current evaluation levels for these conditions are
limited to 30, 10, and zero percent, we propose to provide evaluation
levels of 100, 60, 30, and 10 percent for biliary tract disease or
injury, to accommodate more severe cases, including those that are
totally disabling. We propose to base evaluations on the frequency of
acute attacks of signs and symptoms of biliary tract disease or injury
per year; the frequency of hospitalizations for biliary tract disease
or injury per year; the response to medical or surgical treatment; and
whether liver failure is present. We propose to describe the usual
signs and symptoms of biliary tract disease and injury in a note, as
discussed below.
We propose a 100-percent evaluation for any of the following: Near-
constant debilitating attacks of biliary tract disease or injury that
are refractory to medical or surgical treatment; liver failure; or
hospitalization three or more times per year for biliary tract disease
or injury. We propose a 60-percent evaluation for either of the
following: Six or more attacks of biliary tract disease or injury per
year, partially responsive to treatment; or hospitalization two times
per year for biliary tract disease or injury. We propose a 30-percent
evaluation for either of the following: Three to five attacks of
biliary tract disease or injury per year, or hospitalization once per
year for biliary tract disease or injury. We propose a 10-percent
evaluation for either of the following: One or two attacks of biliary
tract disease or injury per year; or biliary tract pain occurring at
least monthly, despite medical treatment. We propose to remove the
zero-percent level as unnecessary (see Sec. 4.31).
The proposed criteria would provide more objective criteria for
evaluating these conditions and also provide a wider range of
percentage evaluations, consistent with the potential disabling effects
of these conditions.
We propose to add four notes under diagnostic code 7314, with the
first stating that for purposes of evaluation under diagnostic code
7314, attacks of biliary tract disease or injury include any
combination of such signs and symptoms as abdominal pain (including
biliary colic), dyspepsia, jaundice, anorexia (lack or loss of
appetite), nausea, vomiting, chills, and fever (Merck, 242-245). So
that the presence of biliary tract disease is substantiated, and not
based on symptoms alone, the second proposed note would state that
evaluation under diagnostic code 7314 requires that the diagnosis of
any of these conditions be confirmed by X-ray
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or other imaging procedure, laboratory findings, or other objective
evidence. The third proposed note would direct raters to separately
evaluate peritoneal adhesions (diagnostic code 7301) if applicable, and
combine (under the provisions of Sec. 4.25) with an evaluation under
diagnostic code 7314, as long as the same findings are not used to
support more than one evaluation. This would assure that traumatic or
postoperative manifestations due to adhesions would be properly
evaluated. The fourth proposed note would direct raters to evaluate the
cirrhotic phase of sclerosing cholangitis under diagnostic code 7312
(cirrhosis of liver), a more appropriate diagnostic code for evaluating
that condition than 7314.
Since chronic cholelithiasis (current diagnostic code 7315),
chronic cholangitis (current diagnostic code 7316), injury of gall
bladder (current diagnostic code 7317), and removal of gall bladder
(current diagnostic code 7318) would all be included in diagnostic code
7314, for reasons discussed above, we propose to delete the separate
diagnostic codes for those conditions.
Disease or Injury of the Spleen
There is currently a reference to disease or injury of the spleen
under diagnostic code 7318, directing raters to the hemic and lymphatic
systems. We propose to remove that reference as unnecessary, since the
spleen, although in the abdominal cavity, is part of the lymphatic, not
the digestive system. Evaluation criteria for splenectomy (diagnostic
code 7706) and healed injury of the spleen (diagnostic code 7707) are
included in the hemic and lymphatic portion of the rating schedule (38
CFR 4.117), and both conditions are listed in the index to the rating
schedule as part of the hemic and lymphatic systems.
Irritable Bowel Syndrome (Diagnostic Code 7319)
Diagnostic code 7319 is currently titled ``Irritable colon syndrome
(spastic colitis, mucous colitis, etc.).'' We propose to retitle it
``Irritable bowel syndrome (irritable colon, spastic colitis, mucous
colitis),'' since this is current terminology for the condition. The
current evaluation levels are 30, 10, and zero percent. A 30-percent
evaluation is assigned if the condition is severe, with diarrhea or
alternating diarrhea and constipation, with more or less constant
abdominal distress. A 10-percent evaluation is assigned if the
condition is moderate, with frequent episodes of bowel disturbance with
abdominal distress. A zero-percent evaluation is assigned if the
condition is mild, with ``disturbances of bowel function with
occasional episodes of abdominal distress.'' Our consultants suggested
evaluation levels of 30 and 10 percent, with essentially the same
criteria as the current ones, except for adding ``refractory to medical
treatment'' to the criteria for 30 percent, and ``partially responsive
to treatment'' to the criteria for 10 percent. We are proposing to
remove the subjective terms ``severe,'' ``frequent,'' ``occasional,''
etc., from the criteria and to base evaluation on more objective
criteria, in order to decrease the reliance on ambiguous descriptive
terms. We propose a 30-percent evaluation for daily or near-daily
disturbances of bowel function (diarrhea, or alternating diarrhea and
constipation), bloating, and abdominal cramping or pain, refractory to
medical treatment, and a 10-percent evaluation for disturbances of
bowel function (diarrhea, or alternating diarrhea and constipation),
bloating, and abdominal cramping or pain that occur three or more times
a month and that respond partially to medical treatment. We propose to
remove the zero-percent level as unnecessary (see Sec. 4.31). These
proposed criteria would ensure consistency of evaluations and still be
in keeping with our consultants' recommendations.
Amebiasis and Bacillary Dysentery
In the current rating schedule, diagnostic code 7321 is amebiasis,
and diagnostic code 7322 is bacillary dysentery. Both conditions are
uncommon today except as acute short-term illnesses. They ordinarily
resolve without residuals because they are highly responsive to modern
drug treatment. In accordance with our consultants' suggestion, we
therefore propose to delete diagnostic code 7321 and diagnostic code
7322 as unnecessary.
Ulcerative Colitis (Diagnostic Code 7323)
Ulcerative colitis (diagnostic code 7323) is currently evaluated at
100, 60 30, or 10 percent. A 100-percent evaluation is assigned if the
condition is pronounced, resulting in marked malnutrition, anemia, and
general debility, or if there are serious complications, such as liver
abscess. A 60-percent evaluation is assigned if the condition is
severe, with numerous attacks a year and malnutrition, with the health
only fair during remissions. A 30-percent evaluation is assigned if the
condition is moderately severe, with frequent exacerbations; and a 10-
percent evaluation is assigned if the condition is moderate, with
infrequent exacerbations.
The most common symptoms of ulcerative colitis are abdominal pain
and bloody diarrhea, but there may also be rectal pain, fever,
tachycardia, anorexia, malaise, weakness, and other symptoms. In severe
cases, there may be weight loss, malnutrition, anemia, and
hypoalbuminemia. Common complications include perforation, stricture,
hemorrhage, dehydration, fulminant (sudden and intense) colitis, and
toxic megacolon (a severe distention of the colon that can be life
threatening). Among other possible complications are liver disease,
skin nodules, eye problems, colon cancer, and arthritis (Merck, 155-156
and http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm#symptoms, National Digestive Diseases Information
Clearinghouse, February 2006).
Our consultants suggested we continue evaluations based on
frequency of episodes, attacks, and exacerbations, and they provided
some timeframes for their frequency and duration. We propose to use
their suggestions, in a modified form, removing the subjective language
such as ``severe'' and ``marked'' that they included. We also further
propose to specify the usual symptoms of ulcerative colitis in the
criteria, with bloody diarrhea being the major symptom, and to include
criteria based on the need for hospitalization for complications or
continuous treatment with prescription medication. We propose a 100-
percent evaluation for either of the following: malnutrition,
substantial weight loss, anemia, and general debility with multiple
attacks of colitis per year, with bloody diarrhea, abdominal or rectal
pain, fever, and malaise; or hospitalization three or more times per
year for complications such as hemorrhage, dehydration, obstruction,
fulminant (sudden and intense) colitis, toxic megacolon, or
perforation.
We propose a 60-percent evaluation for either of the following:
substantial weight loss and anemia, with multiple attacks of colitis
per year, with bloody diarrhea, abdominal or rectal pain, fever, and
malaise; or hospitalization two times per year for complications such
as hemorrhage, dehydration, obstruction, fulminant colitis, toxic
megacolon, or perforation. We propose a 30-percent evaluation for
either of the following: three or more attacks of colitis (each lasting
5 or more days) per year, with diarrhea with blood, pus, or mucous, and
abdominal or rectal pain; or hospitalization one time per year for
[[Page 39168]]
complications such as hemorrhage, dehydration, obstruction, fulminant
colitis, toxic megacolon, or perforation. We propose a 10-percent
evaluation for either of the following: One or two attacks of colitis
(each lasting 5 or more days) per year with diarrhea with blood, pus,
or mucous, and abdominal or rectal pain; or continuous treatment with
prescription medication either to control symptoms or to maintain
remission.
We also propose to add a note directing raters to evaluate other
complications, such as uveitis, ankylosing spondylitis, sclerosing
cholangitis, etc., separately under an appropriate diagnostic code. We
propose to add a second note directing raters, if there has been a
colon resection, to evaluate under diagnostic codes 7350 (colostomy or
ileostomy) and 7329 (resection of large intestine), as applicable, and
to combine the evaluations under the provisions of Sec. 4.25, as long
as the same findings are not used to support more than one evaluation.
Intestinal Parasitic Infections (Diagnostic Code 7324)
We propose to change the title of diagnostic code 7324 from
``distomiasis, intestinal or hepatic'' to ``parasitic infections of the
intestinal tract'' because our consultants advised us that distomiasis
(formerly used to refer to trematodes or flukes) is a term that is no
longer used. The generic term ``parasitic infections'' includes all
types of parasitic infections, not just trematodes or flukes. Parasitic
infections that do not primarily affect the digestive tract are
evaluated in the portion of the rating schedule that addresses
Infectious Diseases, Immune Disorders and Nutritional Deficiencies. The
current evaluation criteria, with levels of 30, 10, and zero percent,
are based on whether there are ``severe,'' ``moderate,'' or ``mild''
symptoms, with no specific guidance as to the type of symptoms.
Our consultants suggested criteria of ``severe symptoms including
diarrhea, abdominal distress, and weight loss, refractory to medical
treatment'' for a 30-percent evaluation and ``moderate symptoms'' for a
10-percent evaluation. While more specific than the current criteria,
they retain subjective language. We propose to remove the subjective
terms and base evaluation on the presence of diarrhea (which commonly
means more than three loose watery stools in one day (http://digestive.niddk.nih.gov/ddiseases/pubs/diarrhea/, National Digestive
Diseases Information Clearinghouse, October 2003)), abdominal pain, and
weight loss, and on whether continuous treatment with prescription
medication is required. We propose to delete the zero-percent level,
since a parasitic infection that does not meet the criteria for a ten-
percent evaluation would be assigned a non-compensable evaluation, and
this is sufficiently clear without the need for a zero-percent
evaluation level (see Sec. 4.31).
We propose to evaluate parasitic infections of the intestinal tract
at 30 percent if there is daily diarrhea (occurring more than three
times per day) and abdominal pain, with at least minor weight loss. We
propose to evaluate them at 10 percent if diarrhea and abdominal pain
occur, and they require continuous treatment with prescription
medication for control. In addition, since parasitic infection of the
gastrointestinal tract may result in a malabsorption syndrome, we
propose to add a note directing raters to evaluate under proposed
diagnostic code 7353 (malabsorption syndrome), if malabsorption is
present, and doing so would result in a higher evaluation.
Chronic Diarrhea of Unknown Etiology (Diagnostic Code 7325)
Diagnostic code 7325 is currently titled ``Enteritis, chronic'' and
directs that the condition be rated as irritable colon syndrome
(diagnostic code 7319). At the suggestion of our consultants, we
propose to revise the title to ``chronic diarrhea of unknown etiology''
because chronic enteritis is no longer considered a specific diagnostic
entity. We also propose to provide evaluation criteria specific to this
condition, in accordance with the recommendation of our consultants,
since those for evaluating irritable colon syndrome (which include
``alternating constipation and diarrhea'') are not appropriate for
evaluating chronic diarrhea.
We propose to provide evaluation levels of 60, 30, and 10 percent
(our consultants recommended levels of 60 and 30 percent) based on the
frequency of watery bowel movements, their requirement for and response
to medical treatment, and on the number of episodes per year of fluid
and electrolyte imbalance requiring parenteral (intravenous or
intramuscular) hydration. We propose a 60-percent evaluation if there
are five or more watery bowel movements daily, refractory to medical
treatment, and three or more episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or intramuscular)
hydration. We propose a 30-percent evaluation if there are five or more
watery bowel movements daily, partially responsive to medical
treatment, and one or two episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or intramuscular)
hydration. We propose a 10-percent evaluation if the condition requires
continuous treatment with prescription medication for control.
These criteria for evaluating chronic diarrhea of unknown etiology
are both objective and specific to the disability, and are in general
agreement with the suggestions of our consultants, although they
recommended that we require at least six watery bowel movements per
day, instead of five or more, as we are proposing. In our judgment,
five or more watery bowel movements a day constitute a sufficient
indication of severity of the major disabling symptom of this
condition. The consultants also recommended a 60-percent evaluation for
one episode of biochemical alteration, but it is our opinion that one
episode would not be sufficiently disabling to warrant a 60-percent
evaluation, in comparison to other disabilities evaluated at a 60-
percent level. We propose instead that there be three or more episodes
of fluid and electrolyte imbalance to warrant a 60-percent evaluation,
and one or two episodes to warrant a 30-percent evaluation.
Crohn's Disease (Diagnostic Code 7326)
Diagnostic code 7326 is currently titled ``Enterocolitis, chronic''
and directs that the condition be rated as irritable colon syndrome
(diagnostic code 7319), with evaluation levels of 30, 10, and zero-
percent, but as suggested by our consultants, we propose to change the
title to ``Crohn's disease,'' the current medical term for this
condition, and to provide criteria more specific to the disabling
effects of this disease. Our consultants pointed out that Crohn's
disease can be very disabling, and we therefore propose to provide a
broader range of evaluation levels--100, 60, 30, and 10 percent--in
order to encompass the whole range of disabling effects that may result
from this condition. The most common signs and symptoms of Crohn's
disease, which is often episodic, include diarrhea, abdominal pain and
tenderness, fever, anorexia, and weight loss; also there may be pallor,
weakness, malnutrition, abscesses, fistula, bowel obstruction, and
other complications, as pointed out by our consultants, and as found in
standard medical books (Merck, 153; Yamada, 1599).
We propose a 100-percent evaluation for either of the following:
multiple attacks or flareups of Crohn's disease per year with abdominal
pain or tenderness, diarrhea, fever, anorexia
[[Page 39169]]
(lack or loss of appetite), and fatigue plus malnutrition, substantial
weight loss, hypoalbuminemia, and anemia; or hospitalization three or
more times per year for complications such as abscess, stricture,
obstruction, or fistula.
We propose a 60-percent evaluation for any of the following:
multiple attacks or flareups of Crohn's disease per year with abdominal
pain or tenderness, diarrhea, fever, anorexia (lack or loss of
appetite), and fatigue plus substantial weight loss and anemia;
hospitalization two times per year for recurrent complications such as
abscess, stricture, obstruction, or fistula; or constant or near-
constant treatment with high dose systemic (oral or parenteral
[intravenous or intramuscular]) corticosteroids.
We propose a 30-percent evaluation for any of the following: three
or more attacks or flareups of Crohn's disease per year with abdominal
pain or tenderness, diarrhea, fever, anorexia (lack or loss of
appetite), and fatigue, plus at least minor weight loss;
hospitalization one time per year for complications such as abscess,
stricture, obstruction, or fistula; or three or more (but not constant)
courses of treatment per year with high dose systemic (oral or
parenteral [intravenous or intramuscular]) corticosteroids.
We propose a 10-percent evaluation for any of the following: One or
two attacks or flareups of Crohn's disease per year with abdominal pain
or tenderness, diarrhea, and fever; one or two courses of treatment per
year with high dose systemic (oral or parenteral [intravenous or
intramuscular]) corticosteroids; or continuous treatment with
prescription medication other than high dose systemic (oral or
parenteral [intravenous or intramuscular]) corticosteroids.
These criteria are more specific to Crohn's disease than those in
the current rating schedule, and represent modifications of the
criteria suggested by our consultants (for example, to remove
subjective language). They would provide a clear and objective basis
for evaluation, as well as a suitable range of evaluation levels.
We also propose to add a note directing raters to evaluate
complications, such as external gastrointestinal fistula, arthritis,
episcleritis (inflammation of the outer layers of the sclera of the
eye), etc., separately under an appropriate diagnostic code as long as
the same findings are not used to support more than one evaluation (see
Sec. 4.14). We propose to add a second note, because bowel surgery is
often needed, directing raters to evaluate under diagnostic code 7350
(colostomy or ileostomy) if an ostomy is present, and under diagnostic
code 7328 (resection of the small intestine) or 7329 (resection of
large intestine), if applicable, as long as the same findings are not
used to support more than one evaluation.
Diverticulitis (Diagnostic Code 7327)
The current rating schedule does not provide specific criteria for
diverticulitis, diagnostic code 7327, but directs that it be evaluated
as either irritable colon syndrome (diagnostic code 7319), peritoneal
adhesions (diagnostic code 7301), or ulcerative colitis (diagnostic
code 7323), depending on the predominant disability picture. We propose
to provide evaluation criteria specific to this condition, with
evaluation levels of 100, 60, 30, and 10 percent, to reflect its range
of severity. The most common signs and symptoms of diverticulitis are
abdominal pain and tenderness, fever, and an elevated white blood count
(Merck, 160; Yamada, 1737). There may also be peritoneal irritation,
with or without bleeding; irregular defecation; and such complications
as fistula formation, intestinal obstruction, abscess formation, or
perforation. Milder attacks can be treated with antibiotics, bed rest,
and a liquid diet as an outpatient, but more serious attacks may
require hospitalization for intravenous antibiotics and other measures,
and, sometimes, surgery.
We therefore propose a 100-percent evaluation for either of the
following: near-constant signs and symptoms of diverticulitis, with
abdominal pain and tenderness, fever, and irregular defecation
(constipation, diarrhea, or alternating constipation and diarrhea); or
hospitalization at least three times per year for complications such as
abscess, perforation, obstruction, or fistula.
We propose a 60-percent evaluation for any of the following: six or
more attacks of diverticulitis per year with abdominal pain and
tenderness, fever, and irregular defecation (constipation, diarrhea, or
alternating constipation and diarrhea), requiring outpatient treatment
with a course of antibiotics, bed rest, and a liquid diet;
hospitalization two times per year for complications such as abscess,
perforation, obstruction, or fistula; or hospitalization three or more
times per year for acute diverticulitis requiring intravenous
antibiotics.
We propose a 30-percent evaluation for any of the following: three
to five attacks of diverticulitis per year with abdominal pain and
tenderness, fever, and irregular defecation (constipation, diarrhea, or
alternating constipation and diarrhea), requiring outpatient treatment
with a course of antibiotics, bed rest, and a liquid diet;
hospitalization one time per year for complications such as abscess,
perforation, obstruction, or fistula; or hospitalization once or twice
per year for acute diverticulitis requiring intravenous antibiotics.
We propose a 10-percent evaluation for the following: One or two
attacks of diverticulitis per year with abdominal pain and tenderness,
fever, and irregular defecation (constipation, diarrhea, or alternating
constipation and diarrhea), requiring a course of antibiotics.
We also propose to add a note to address evaluation after surgery,
which is often needed to treat diverticulitis. The note would direct
raters to evaluate under diagnostic code 7350 (colostomy or ileostomy)
if an ostomy is present, and under diagnostic code 7329 (resection of
large intestine), if applicable, as long as the same findings are not
used to support more than one evaluation (see Sec. 4.14).
These criteria are similar to those suggested by our consultants,
but modified, to remove indefinite terms such as ``severe,''
``moderate,'' and ``frequent,'' and to substitute criteria that are
both more specific and more objective, in order to promote consistent
evaluations.
Resection of Small Intestine (Diagnostic Code 7328)
Resection of the small intestine, diagnostic code 7328, currently
has evaluation levels of 60, 40 and 20 percent, with criteria for the
various levels based on the extent of interference with absorption and
nutrition, the degree of impairment of health with either weight loss
or inability to gain weight, and whether there are symptoms. A 60-
percent evaluation is assigned 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 indefinite criteria, such as
``material'' or ``definite'' weight loss and ``marked'' or ``definite''
interference with absorption. In addition, our consultants advised us
that the current criteria, based partly on weight loss or inability to
gain weight, are no longer
[[Page 39170]]
appropriate because the parenteral (intravenous or intramuscular) and
supplemental nutrition now available will ordinarily allow body weight
to be maintained. They pointed out that the type and frequency of
nutritional support needed is related to the severity of the condition.
We therefore propose to provide evaluation criteria that are both
more objective and more characteristic of the disabling effects of
resection of the small intestine than the current criteria, in light of
modern medicine. We propose that the condition be evaluated based on
the need for oral or parenteral (intravenous or intramuscular)
nutritional support and on the presence of diarrhea and other symptoms.
Our consultants said that the need for total parenteral (intravenous or
intramuscular) nutrition indicates a debilitating condition that would
be totally disabling. We therefore propose a 100-percent evaluation if
total parenteral (intravenous or intramuscular) nutrition is required.
We propose a 60-percent evaluation for diarrhea, weakness, fatigue,
abdominal cramps, and bloating, with anemia, requiring daily (oral)
nutritional supplementation, plus parenteral (intravenous or
intramuscular) nutrition for a total of at least 28 days per year; a
30-percent evaluation for diarrhea, weakness, fatigue, abdominal
cramps, and bloating requiring daily (oral) nutritional supplementation
plus parenteral (intravenous or intramuscular) nutrition for a total of
at least 14 days, but less than 28 days per year; and a 10-percent
evaluation for diarrhea, weakness, fatigue, abdominal cramps, and
bloating requiring daily (oral) nutritional supplementation.
We propose to modify the current note under diagnostic code 7328.
It now directs that the condition be rated under diagnostic code 7301,
where residual adhesions constitute the predominant disability. We
propose that the note instruct raters to separately evaluate peritoneal
adhesions, diagnostic code 7301, if applicable, as long as the same
findings are not used to support an evaluation both under diagnostic
code 7301 and under diagnostic code 7328.
Resection of Large Intestine (Diagnostic Code 7329)
Resection of the large intestine, diagnostic code 7329, currently
has evaluation levels of 40, 20, and 10 percent, based on the
indefinite criteria of whether symptoms are ``severe'' and
``objectively supported by examination findings'' (for 40 percent),
``moderate'' (for 20 percent), or ``slight'' (for 10 percent). We
propose to remove these subjective terms and provide more objective
criteria based on the primary symptoms of diarrhea and abdominal pain
and the number of complications, as recommended by our consultants. We
propose that there be a broader range of evaluation levels, 100, 60,
30, and 10 percent, consistent with the range of severity of the
condition.
We propose a 100-percent evaluation for multiple daily episodes of
diarrhea and abdominal pain that are refractory to treatment, plus at
least two hospitalizations per year for complications such as
obstruction, fistula, or abscess; a 60-percent evaluation for multiple
attacks of diarrhea and abdominal pain per year requiring medical
treatment plus at least one hospitalization per year for complications
such as obstruction, fistula, or abscess; a 30-percent evaluation for
four or more attacks of diarrhea and abdominal pain per year requiring
medical treatment; and a 10-percent evaluation for two or three attacks
per year of diarrhea and abdominal pain requiring medical treatment.
These criteria are more objective and would therefore promote more
consistent evaluations, and they are consistent with the disabling
effects that sometimes occur after large bowel resection. They are
similar to the suggestions of our consultants, but with less subjective
language and with modifications of the criteria at various levels, for
the sake of internal consistency.
Although the current note following diagnostic code 7329 instructs
raters to evaluate the condition as peritoneal adhesions, diagnostic
code 7301, if adhesions are the predominant disability, we propose to
direct raters to separately evaluate peritoneal adhesions (diagnostic
code 7301), if applicable, and combine (under the provisions of Sec.
4.25) with an evaluation under diagnostic code 7329, as long as the
same findings are not used to support more than one evaluation. This is
clearer and more appropriate, since evaluation under both cited
diagnostic codes is feasible under certain circumstances (see Sec.
4.14, Avoidance of pyramiding). We also propose to add a second note
directing raters to evaluate under diagnostic code 7350 (colostomy or
ileostomy), if applicable, and combine (under the provisions of Sec.
4.25) with an evaluation under diagnostic code 7329, as long as the
same findings are not used to support more than one evaluation.
External Gastrointestinal Fistula (Diagnostic Code 7330)
Diagnostic code 7330 is currently titled ``Intestine, fistula of,
persistent, or after attempt at operative closure.'' External
gastrointestinal fistulas (fistulas that drain from the
gastrointestinal tract to the surface of the skin) other than fistulas
from the intestine are not currently included in the rating schedule.
Our consultants stated that the symptoms and complications of external
gastrointestinal fistula include fluid discharge, skin problems, fluid
and electrolyte imbalance, recurrent sepsis, and malnutrition. We
propose to base the evaluation on such manifestations, regardless of
the type of discharge, rather than solely on the presence and amount of
the discharge. Only fecal discharge is currently evaluated under this
diagnostic code, and the criteria do not take into account the type of
treatment or the potential specific effects that might result from
fecal or other types of discharges. As recommended by our consultants,
we propose to expand the category of fistula of the intestine and
change the title to ``external gastrointestinal fistula (including
biliary, pancreatic, esophageal, gastric, and intestinal fistulas)'' in
order to include all external fistulas of gastrointestinal origin. The
current criteria are ``copious and frequent, fecal discharge'' for a
100-percent evaluation; ``constant or frequent, fecal discharge'' for a
60-percent evaluation; and ``slight infrequent, fecal discharge'' for a
30-percent evaluation. The current provision also directs that if
healed, fistulas are to be rated as peritoneal adhesions. We propose to
delete the ambiguous and subjective terms ``slight,'' ``frequent,'' and
``infrequent,'' and replace them with more objective and specific
criteria, in order to assure more consistent evaluations. We also
propose to delete the reference to fecal discharge because we are
proposing that this diagnostic code include fistulas where the
discharge may be bile, gastric fluid, etc., instead of fecal material.
We also propose to delete the direction to rate healed fistulas as
peritoneal adhesions, since our consultants said that adhesions are not
a usual complication of fistulas.
Our consultants stated that the symptoms and complications of
external gastrointestinal fistula include fluid discharge, skin
problems, fluid and electrolyte imbalance, recurrent sepsis, and
malnutrition. We propose to base the evaluation on such manifestations,
[[Page 39171]]
rather than simply on the extent and frequency of fecal discharge.
We propose a 100-percent evaluation for external gastrointestinal
fistula if there is constant or near-constant copious discharge that
cannot be contained, and any of the following is present: A need for
total parenteral (intravenous or intramuscular) nutritional support,
malnutrition, seven or more episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or intramuscular)
hydration, or two or more episodes per year of sepsis (a serious and
sometimes life-threatening infection with a widespread inflammatory
response). We propose a 60-percent evaluation for constant or near-
constant copious discharge that cannot be contained, and with any of
the following: Persistent skin breakdown, despite treatment, five or
six episodes per year of fluid and electrolyte imbalance requiring
parenteral (intravenous or intramuscular) hydration, or one episode of
sepsis per year. We propose a 30-percent evaluation for constant or
intermittent discharge with either of the following: Six or more
episodes per year of skin breakdown requiring treatment, or two to four
episodes per year of fluid and electrolyte imbalance requiring
parenteral (intravenous or intramuscular) hydration. We propose a 10-
percent evaluation for constant or intermittent discharge with either
of the following: At least two, but less than six, episodes per year of
skin breakdown requiring treatment, or one episode per year of fluid
and electrolyte imbalance requiring parenteral (intravenous or
intramuscular) hydration.
The proposed criteria are more precise and better take into account
the actual disabling effects of a fistula. These changes would provide
raters with clearly delineated objective criteria for evaluation and
are in general agreement with revisions suggested by our consultants.
Our consultants recommended that we direct raters to evaluate internal
gastrointestinal fistulas (fistulas that drain from one area of the
gastrointestinal tract to another) under the criteria for malabsorption
(diagnostic code 7353) or other appropriate condition, depending on the
particular findings, since malabsorption is a common effect of internal
fistulas. We propose to add this direction in a note under diagnostic
code 7330.
Tuberculous Peritonitis (Diagnostic Code 7331)
Diagnostic code 7331, ``peritonitis, tuberculous, active or
inactive,'' currently directs that inactive tuberculous peritonitis be
evaluated under Sec. Sec. 4.88b or 4.89 (of this part). We propose to
correct this reference because Sec. 4.88b was redesignated Sec. 4.88c
in a separate rulemaking (59 FR 60902), which was published in the
Federal Register on November 29, 1994. The correct section references
should be 4.88c and 4.89. Otherwise, we propose no change to the rating
criteria, but we do propose to simplify the title of this diagnostic
code to ``Tuberculous peritonitis.''
Impaired Control of the Anal Sphincter (Diagnostic Code 7332)
Diagnostic code 7332 is currently titled ``Rectum and anus,
impairment of sphincter control.'' We propose to change the title to
``Impaired control of the anal sphincter (anal incontinence)'' for more
accuracy, because our consultants stated that inclusion of the rectum
in this category is not appropriate, since the sphincter is actually an
anal, rather than a rectal, structure. There are currently evaluation
levels of 100, 60, 30, 10 and zero percent. A 100-percent evaluation is
assigned if there is complete loss of sphincter control; a 60-percent
evaluation if there is extensive leakage and fairly frequent
involuntary bowel movements; a 30-percent evaluation if there are
occasional involuntary bowel movements necessitating wearing of pad; a
10-percent evaluation if there is constant slight, or occasional
moderate leakage; and a zero-percent evaluation if the condition is
healed or slight, without leakage. These criteria contain numerous
indefinite terms, such as ``extensive,'' ``frequent,'' ``occasional,''
and ``slight,'' that allow different individuals to make different
interpretations of the criteria.
We propose to retain evaluation levels of 100, 60, 30, and 10
percent, but omit the zero-percent evaluation level as unnecessary (see
Sec. 4.31). We further propose to make the criteria more objective by
basing them on the specific frequency of fecal soiling, the extent of
inability to control solid or liquid feces, and the need for wearing
absorbent material. We propose a 100-percent evaluation if there is
complete inability to control solid and liquid feces; a 60-percent
evaluation if there is daily fecal soiling and complete inability to
control liquid feces; a 30-percent evaluation if there is fecal soiling
that, although less than daily, is frequent enough or extensive enough
to require daily wearing of absorbent material; and a 10-percent
evaluation if there is fecal soiling that is intermittent, and not
frequent enough or extensive enough to require daily wearing of
absorbent material. We propose to remove the zero-percent level as
unnecessary (see Sec. 4.31). These more objective and condition-
specific criteria would promote consistent evaluations of this
disability and are in general agreement with, although more detailed
than, the revisions suggested by our consultants. They also exclude the
subjective terms such as ``pronounced'' and ``moderate'' that our
consultants used. We also propose to add a note directing raters to
evaluate under diagnostic code 7350 (colostomy or ileostomy) if an
ostomy is present, since fecal incontinence may require a colostomy.
Stricture of the Anus (Diagnostic Code 7333)
Diagnostic code 7333 is currently titled ``Rectum and anus,
stricture of.'' Because our consultants suggested that rectal
strictures would be more appropriately evaluated with bowel strictures
under diagnostic code 7349, we propose to remove rectal strictures from
this diagnostic code and change the title to ``Stricture of the anus.''
The current evaluation criteria are ``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. We propose to
remove the indefinite terms, such as ``great,'' ``extensive,'' and
``moderate,'' and base the evaluation on objective criteria, such as
the extent of reduction of the lumen, the frequency and extent of fecal
soiling, and the necessity for daily wearing of absorbent material.
Because we are proposing a separate diagnostic code for the
evaluation of colostomy and ileostomy, there is no longer a need to
include colostomy in these criteria. We propose to change the current
evaluation levels of 100, 50, and 30 percent to 100, 60, and 30
percent, and to add a 10-percent level, for the sake of more internal
consistency. These are also the levels we propose to provide for
diagnostic code 7332, and the type and range of disability due to this
condition are very similar to those of disability due to impaired
control of the anal sphincter. We propose a 100-percent evaluation if
there is inability to open or completely close the anus, with complete
inability to control liquid or solid feces. We propose a 60-percent
evaluation if there is reduction of the lumen by at least 50 percent,
with pain and prolonged straining during defecation, and complete
inability to control liquid feces. We propose a 30-percent evaluation
if there is reduction of the lumen, but by less than 50 percent, with
straining during
[[Page 39172]]
defecation, and fecal incontinence that requires daily wearing of
absorbent material; and a 10-percent evaluation if there is reduction
of the lumen, with fecal soiling that is not frequent enough or
extensive enough to require daily wearing of absorbent material.
Because a colostomy may be required for treatment of this
condition, we also propose to add a note directing raters to evaluate
under diagnostic code 7350 (colostomy or ileostomy), if an ostomy is
present. In addition to proposing more objective criteria in order to
promote consistency of evaluations, we have proposed criteria that are
generally in agreement with our consultants' suggestions, excluding the
subjective modifiers, such as ``moderate'' and ``occasional,'' that
they used. These criteria are also internally consistent with the
proposed criteria for evaluating impaired control of the anal
sphincter.
Prolapse of Rectum (Diagnostic Code 7334)
Diagnostic code 7334, ``rectum, prolapse of,'' currently has
evaluation levels of 50, 30, and 10 percent. A 50-percent evaluation is
assigned if there is ``severe (or complete), persistent'' rectal
prolapse. A 30-percent evaluation is assigned if there is ``moderate,
persistent or frequently recurring'' rectal prolapse, and a 10-percent
evaluation is assigned if there is mild rectal prolapse, ``with
constant slight or occasional moderate leakage.'' These criteria
require raters to subjectively determine whether the condition is
``mild,'' ``moderate,'' or ``severe,'' and what level of frequency the
term ``frequently recurring'' implies.
Our consultants noted that incontinence is the major problem
associated with prolapse of the rectum and that higher evaluation
levels should be available for this condition. We therefore propose to
provide levels of 100, 60, 30, and 10 percent, as we are proposing for
diagnostic codes 7332 and 7333, the codes for other conditions that are
also characterized primarily by fecal incontinence. We propose to
remove the subjective language and base evaluation on more objective
criteria, such as the frequency of prolapse, the presence of
incontinence, and the extent of fecal soiling.
We propose a 100-percent evaluation for persistent prolapse with
complete inability to control liquid or solid feces; a 60-percent
evaluation for intermittent prolapse (occurring three or more times
weekly) with complete inability to control liquid or solid feces during
periods of prolapse; a 30-percent evaluation for intermittent prolapse
(occurring three or more times weekly) without complete inability to
control liquid or solid feces during periods of prolapse, but with
difficulty in bowel evacuation and fecal soiling that is frequent
enough or extensive enough to require daily wearing of absorbent
material; and a 10-percent evaluation if there is intermittent prolapse
with difficulty in bowel evacuation and fecal soiling that is not
frequent enough or extensive enough to require daily wearing of
absorbent material.
These criteria would promote more consistent evaluations, and they
provide a range of evaluation levels consistent with the range of
severity of this condition. Our consultants recommended criteria based
on frequency of prolapse, whether or not there is incontinence,
difficult evacuation, and soiling. However, they used numerous
subjective terms, such as ``mild,'' ``moderate,'' ``severe,''
``frequently,'' and ``occasional,'' and our proposed criteria represent
a modification of their recommendations for the sake of objectivity and
internal consistency with other digestive condition evaluations.
Our consultants also recommended that solitary rectal ulcer
syndrome be included in this code. However, in our experience, this
condition occurs too infrequently to warrant inclusion, and in
addition, the symptoms of solitary rectal ulcer syndrome--altered bowel
habits with blood and mucous in the stool, anorectal pain, a feeling of
incomplete evacuation, and straining at defecation (Yamada, 1824)--are
not entirely consistent with the condition-specific criteria we are
proposing for rectal prolapse. If solitary rectal ulcer syndrome
requires evaluation, it may be rated as an analogous condition under
the evaluation criteria for prolapse of the rectum or other digestive
condition in the rating schedule, depending on the particular signs and
symptoms found.
Fistula in Ano (Diagnostic Code 7335)
Fistula in ano, diagnostic code 7335, is currently evaluated as
impairment of sphincter control, diagnostic code 7332. The current
evaluation criteria for impairment of sphincter control are not ideal
for evaluating fistula in ano, however, because they do not take into
account abscesses with pain and drainage, which our consultants pointed
out are the primary disabling effects of fistulas. We therefore propose
to provide a specific set of evaluation criteria based on these
effects, with evaluation levels of 100, 60, 30, and 10 percent, the
same levels as for other anal disabilities.
Fistula in ano may also be called anorectal fistula or anorectal
abscess, and we propose to add those names to the title. We propose a
100-percent evaluation for fistula in ano with constant or near-
constant abscesses with drainage and pain that are refractory to
medical and surgical treatment; a 60-percent evaluation for four or
more abscesses (each lasting a week or more) per year with drainage and
pain; a 30-percent evaluation for three or more abscesses (each lasting
less than a week) per year with drainage and pain ; and a 10-percent
evaluation either for one or two abscesses (each lasting less than a
week) per year with drainage and pain, or for a fistula with pain and
discharge but without associated abscesses. We propose to delete the
zero-percent evaluation as unnecessary for clarity (see Sec. 4.31).
These evaluation criteria are better suited and more appropriate for
evaluating this disability because, in addition to being more
objective, they are based on the usual disabling effects of fistula in
ano. They represent modifications of the suggestions made by our
consultants, faithful in substance, but with some changes made partly
for the sake of internal consistency and partly to remove subjective
terms.
Our consultants suggested we add a diagnostic code for the
evaluation of other defecation disorders, such as Hirschprung's disease
(congenital megacolon), anismus (paradoxical pelvic muscle
contraction), levator spasm syndrome, functional constipation, and
outlet obstruction. We do not propose to do so because these conditions
are either uncommon in our experience, congenital in origin and likely
to disqualify for military service, or have no organic basis. Any
condition that requires evaluation for compensation purposes can be
evaluated under existing codes as an analogous condition.
Hemorrhoids (Diagnostic Code 7336)
Hemorrhoids, external or internal, (diagnostic code 7336) are
currently evaluated at 20, 10, or zero percent. A 20-percent evaluation
is provided 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 zero-percent evaluation if they are
``mild or moderate.'' According to our consultants, external
hemorrhoids are seldom chronically disabling, but can cause
intermittent problems when they undergo thrombosis. Internal
hemorrhoids may undergo frequent or permanent prolapse, thrombosis, and
bleeding sufficient to cause anemia. The
[[Page 39173]]
current evaluation criteria under diagnostic code 7336 do not
differentiate between internal and external hemorrhoids.
We propose to change the title of diagnostic code 7336 from
``hemorrhoids, external or internal'' to ``hemorrhoids,'' because the
single term encompasses all types of hemorrhoids, and to provide
criteria that apply in part to any type of hemorrhoids and in part only
to either internal or external hemorrhoids. We propose to retain
evaluation levels of 20 and 10 percent, but to remove the zero-percent
evaluation criteria as unnecessary (see Sec. 4.31). We also propose to
remove subjective terms such as ``mild,'' ``moderate,'' ``excessive,''
and ``frequent'' that are in the current criteria and replace them with
more objective criteria. We propose a 20-percent evaluation for either
of the following: Persistent bleeding with anemia, or permanently
prolapsed internal hemorrhoids with three or more episodes per year of
thrombosis. We propose a 10-percent evaluation for either permanently
or intermittently prolapsed internal hemorrhoids with one or two
episodes per year of thrombosis, or for external hemorrhoids with three
or more episodes per year of thrombosis. These criteria would provide
raters with a clear, objective way to evaluate any type of hemorrhoids,
while taking into account the differences in the disabling effects of
external and internal hemorrhoids.
Hernia, Inguinal or Femoral (Diagnostic Code 7338)
Inguinal hernia, diagnostic code 7338, and femoral hernia,
diagnostic code 7340, have similar disabling effects and are currently
rated under the same criteria. There is no statistical need for VA
purposes to retain separate diagnostic codes for each type of hernia,
and we therefore propose to combine them under diagnostic code 7338,
and retitle that diagnostic code ``Hernia, inguinal or femoral (both
post-operative recurrent and non-operated).'' We propose to delete
diagnostic code 7340. The issue of whether or not a hernia had been
previously repaired is part of the current evaluation criteria, but we
are proposing criteria that would apply to both initial and recurrent
hernias because the potential signs and symptoms are the same. At the
time the current evaluation criteria were developed, the repair of
recurrent hernias, which is more difficult than the repair of initial
hernias, was not as reliable or effective as it is with modern surgical
techniques for hernia repair, such as the use of mesh to cover a hernia
defect (first introduced in 1962 (http://www.ednf.org/medical/content/view/321/38/, Ehlers-Danlos National Foundation, 2006)) and surgical
repair performed by laparoscopy (first described in 1990 (http://www.rcsed.ac.uk/Journal/vol45_1/4510006.htm, P. Ridings and D.S.
Evans, J.R.Coll.Surg.Edinb., 45; 1: 29-32, February 2000)). Therefore,
we do not propose to include the fact that a hernia is or is not
recurrent in the evaluation criteria. Recurrent (or initial) hernias
that cannot be repaired are encompassed by the evaluation criterion of
``cannot be corrected by surgery'' in proposed diagnostic code 7338 at
the 60- and 30-percent evaluation levels, and complications resulting
from the repair of any hernia can be evaluated separately.
The current evaluation levels are 60, 30, 10, and zero percent, and
we propose to retain all but the zero-percent level. A 60-percent
evaluation is now assigned for a hernia that is ``large, postoperative,
recurrent, not well supported under ordinary conditions and not readily
reducible, when considered inoperable;'' a 30-percent evaluation for a
hernia that is ``small, postoperative recurrent, or unoperated
irremediable, not well supported by truss, or not readily reducible;''
a 10-percent evaluation for a hernia that is ``postoperative recurrent,
readily reducible and well supported by truss or belt;'' and a zero-
percent evaluation both for a hernia that is ``not operated, but
remediable'' and for one that is ``small, reducible, or without true
hernia protrusion.''
We propose to remove the subjective terms and provide more
objective criteria, for example, replacing ``large'' and ``small'' with
the actual greatest diameter of the hernia, in order to remove
ambiguity. Since both femoral and inguinal hernias may or may not be
correctable by surgery (although not being correctable is less common
with modern surgical and anesthetic techniques), may or may not be
supportable by external devices, and may or may not be easily
reducible, regardless of whether or not they have been operated, we
propose to differentiate the criteria for 60- and 30-percent
evaluations only on the basis of the size of the hernia. We propose a
60-percent evaluation for a hernia with all of the following: greatest
diameter is 15 centimeters (5.91 inches) or more, cannot be corrected
by surgery, and requires support but is not well supported by external
devices or is not easily reducible; a 30-percent evaluation for a
hernia with the same findings as for a 60-percent evaluation except for
a greatest diameter that is less than 15 centimeters; and a 10-percent
evaluation for a hernia with all of the following: is of any size, can
be corrected by surgery, requires support and is supportable by
external devices, and is easily reducible. We do not propose to retain
a zero-percent level as it is not needed for clarity (see Sec. 4.31).
In addition to being more objective, these criteria provide sharper
distinctions between the levels of disability. There is currently a
note under this diagnostic code directing raters to add 10 percent for
bilateral involvement, provided the second hernia is compensable, and
explaining that this means that the more severely disabling hernia is
to be evaluated, and 10 percent only is to be added for the second
hernia, if the latter is of compensable degree. In our judgment, two
hernias, each of which meets the criteria for a 60-percent evaluation,
for example, would be more disabling in combination than two hernias,
one of which meets the criteria for a 60-percent evaluation, and the
other for a 10-percent evaluation, although under current regulations
they would be evaluated the same. We therefore propose to remove this
note, and to replace it with a note directing that each hernia be
separately evaluated and the evaluations combined (under the provisions
of Sec. 4.25).
Our consultants suggested evaluation levels for inguinal and
femoral hernias of 80 10, and zero percent. We do not believe that this
sequence of evaluation levels would allow adequate assessment of the
potential disabling effects of femoral and inguinal hernias because of
the very large gap between the 80- and 10-percent evaluation levels. In
our judgment, some hernias would fall into a level of severity between
these levels. In addition, based on our experience, including an 80-
percent level is not warranted because there are very few veterans with
hernias that are currently evaluated at a level higher than 30 percent.
It is very unlikely that evaluations as high as 80 percent would be
appropriate or necessary. For the exceptional case that might present a
picture of disability more severe than is warranted under the proposed
60-percent upper limit of evaluation, 38 CFR 3.321(b)(1), which
provides for extra-schedular evaluations in cases where an evaluation
is inadequate because the condition presents such an unusual disability
picture that applying the regular schedular standards would be
impractical, provides a way to assign a higher evaluation. The
consultants' suggested evaluation criteria also included subjective
language such as
[[Page 39174]]
``moderate,'' ``mild,'' and ``small,'' and they retained the references
to recurrent hernia. We have already explained why we are not basing
evaluation on whether or not a hernia is recurrent. In addition, they
suggested using pain as one of the criteria, but, in our judgment, the
more objective criteria we are proposing would take pain, a subjective
symptom, into account as part of the effects of a hernia (for example,
as part of whether or not a hernia is supportable or reducible, and its
size), and the more objective criteria would promote accurate and more
consistent evaluations. For these reasons, we do not propose to adopt
our consultants' suggestions for the evaluation of hernias.
Ventral Hernia, Postoperative (Diagnostic Code 7339)
Diagnostic code 7339 is currently titled ``Hernia, ventral,
postoperative.'' We propose to retitle this diagnostic code as
``Ventral (incisional) hernia, and other abdominal hernias
postoperative.'' ``Incisional'' is another term for ventral hernia, and
other incisional hernias that might not be ventral (flank incisions,
for example), would also be most appropriately evaluated under this
diagnostic code. Ventral hernia is currently evaluated at levels of
100, 40, 20, and zero percent. A 100-percent evaluation is assigned if
a ventral hernia is massive, persistent, and there is severe diastasis
of recti muscles or extensive diffuse destruction or weakening of
muscular and fascial support of the abdominal wall so as to be
inoperable; a 40-percent evaluation if a hernia is large and not well
supported by a belt under ordinary conditions; a 20-percent evaluation
if a hernia is small and not well supported by a belt under ordinary
conditions, or if there is a healed ventral hernia or postoperative
wounds with weakening of the abdominal wall and there is an indication
for a supporting belt; and a zero-percent evaluation if there are
postoperative wounds that are healed, with no disability, and a belt is
not indicated. These criteria contain the indefinite terms ``massive,''
``large,'' and ``small,'' which could be interpreted differently by
different people.
According to our consultants, whether or not a ventral hernia is
supportable is more useful than size, which is currently used to
distinguish between the 20- and 40-percent levels of disability.
However, both to distinguish more clearly the levels of evaluation, and
because, in our judgment, a large hernia that is not supportable is
likely to interfere with activities more than a small non-supportable
hernia, we propose to base evaluation in part on size, but also in part
on whether or not the hernia is externally supportable. The presence of
pain or incarceration (being irreducible) is also relevant to the
extent of disability, according to our consultants. However, as
discussed above under inguinal and femoral hernias, we consider pain to
be included as part of the effects of other criteria we are proposing
to use.
We propose evaluation levels of 100, 60, 30, and 10 percent for
ventral hernia, instead of the current levels of 100, 40, 20, and zero
percent. These levels would provide a range of evaluations appropriate
to ventral hernias, and allow a clear distinction between the levels,
while eliminating the large gap between 100 and 40 percent. In our
opinion, some hernias would fall into the area between 100 and 40
percent levels of severity. The evaluation levels are also comparable
to the proposed levels for inguinal and femoral hernia under diagnostic
code 7338.
We propose to revise the criteria to make them less ambiguous and
clearer for more ease of use and consistency of evaluations. For
example, we propose to provide an evaluation of 100 percent for a
hernia with a diameter of 30 or more centimeters, rather than employing
the term ``massive''. In our judgment, a ventral hernia with a diameter
of 30 centimeters (11.81 inches) or greater is a hernia of such size
that it would be totally disabling if it cannot be repaired because of
loss of tissue support. We also propose to remove the reference to
diastasis of recti muscles because our consultants pointed out that
diastasis recti is a congenital condition of the abdominal wall that is
not necessarily accompanied by a hernia. We further propose to
substitute ``refractory to further operative correction due to
extensive loss of muscular and fascial support'' in lieu of considered
``inoperable'' to indicate that it must be the status of the hernia
itself, rather than unrelated medical reasons, that makes the hernia
unsuitable for surgical correction.
We therefore propose a 100-percent evaluation for a ventral hernia
with both of the following: greatest diameter is 30 centimeters (11.81
inches) or more and is refractory to further operative correction due
to extensive loss of muscular and fascial support. We propose a 60-
percent evaluation for a ventral hernia with both of the following:
greatest diameter is 20 centimeters (7.87 inches) or more and requires
support but is not well supported by external devices or is not easily
reducible. We propose a 30-percent evaluation for the same criteria as
for a 60-percent evaluation except that it applies to a ventral hernia
with greatest diameter less than 20 centimeters (7.87 inches), and a
10-percent evaluation for a ventral hernia of any size that requires
support, and is supportable by external devices, and that is easily
reducible. We also propose to delete the zero-percent level, with
current criteria of postoperative wounds that are healed, with no
disability, and a belt not indicated, since those criteria all indicate
the absence of any disability and are not necessary for evaluation.
Visceroptosis
Our consultants noted that the term ``visceroptosis,'' the title of
current diagnostic code 7342, is obsolete. This term was used to
describe variations in positions of the organs in the body, which
medical practitioners once considered to be significant. The differing
positions of the organs are currently viewed as normal anatomical
variations that are of no pathological significance. We therefore
propose to delete diagnostic code 7342 from the schedule.
Gastroesophageal Reflux Disease (Diagnostic Code 7346)
Hiatal hernia is currently evaluated under diagnostic code 7346.
According to our consultants, the most disabling manifestation of
hiatal hernia is gastroesophageal reflux. To reflect this fact, we
propose to change the title of diagnostic code 7346 from ``hernia
hiatal'' to ``gastroesophageal reflux disease (GERD), hiatal hernia,
esophagitis, lower esophageal (Schatzki's) ring.'' These conditions are
closely related, and their symptoms overlap, so evaluating them under
the same criteria is appropriate and would promote more consistent
evaluations. The current evaluation levels are 60, 30, and 10 percent.
We propose to retain these levels, and to add a zero-percent level for
the sake of clarity. The current criteria under diagnostic code 7346
call for a 60-percent evaluation if there are ``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 if there is
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 if there are two or more of the same symptoms as for the 30-
percent evaluation, but of less severity.
[[Page 39175]]
These criteria rely on subjective interpretations of terms such as
``severe'' or ``considerable'' impairment of health, symptoms of ``less
severity,'' and ``persistently recurrent'' symptoms and could lead to
different interpretations by different individuals. We propose to
remove the indefinite language and base evaluation on more objective
criteria that are also more inclusive of the effects of this group of
conditions than the current evaluation criteria. The proposed criteria
would be based on such signs and symptoms as the presence of erosive
reflux esophagitis, anemia, hemorrhage, weight loss, and pulmonary
aspiration, and of certain symptoms such as pyrosis, retrosternal or
arm or shoulder pain, dysphagia, and odynophagia.
We propose a 60-percent evaluation for erosive reflux esophagitis
(inflammation and ulceration of the esophagus due to reflux of gastric
contents into the esophagus) confirmed by endoscopy, imaging, or other
laboratory procedure, with at least one of the following: anemia and
substantial weight loss, one or more episodes per year of
gastrointestinal hemorrhage, or two or more episodes per year of
pulmonary aspiration (with bronchitis, pneumonia, or pulmonary abscess)
due to regurgitation. We propose a 30-percent evaluation for confirmed
erosive reflux esophagitis, with symptoms such as pyrosis (heartburn),
retrosternal or arm or shoulder pain, regurgitation of gastric contents
into the mouth, dysphagia (difficulty swallowing), and odynophagia
(pain during swallowing) that are intractable despite treatment, or
with one episode per year of pulmonary aspiration (with bronchitis,
pneumonia, or pulmonary abscess) due to regurgitation. We propose a 10-
percent evaluation for the same symptoms as for the 30-percent level,
but that are largely controlled by continuous treatment with
prescription medication; and a zero-percent evaluation for the same
symptoms, but that are intermittent and that respond to dietary
changes, lifestyle changes, or treatment with antacids or other
nonprescription medications. In this case, we are proposing a zero-
percent level because the criteria that are provided list items such as
lifestyle and dietary changes that are not otherwise addressed in the
criteria but that are used to treat these conditions, and it might be
unclear to raters whether they warrant a zero- or a 10-percent
evaluation. These criteria are in general agreement with the
suggestions of our consultants, but with replacement of subjective
language such as ``mild,'' ``moderate,'' and ``severe'' with more
objective criteria.
We also propose to add a note directing that raters evaluate
esophageal stricture, which may result from esophagitis, under the
General Rating Formula for Residuals of mouth injuries (7200),
Residuals of lip injuries (7201), Residuals of tongue injuries,
including tongue loss (7202), Esophageal stricture (7203), Achalasia
(cardiospasm) and other motor disorders of the esophagus (7204), and
Esophageal diverticula (7205).
Pancreatitis, Total Pancreatectomy, and Partial Pancreatectomy
(Diagnostic Code 7347)
Diagnostic code 7347, pancreatitis, is currently evaluated at
levels of 100, 60, 30, or 10 percent. The criteria call for a 100-
percent evaluation if there are frequently recurrent disabling attacks
of abdominal pain with few pain free intermissions and with
steatorrhea, malabsorption, diarrhea and severe malnutrition; a 60-
percent evaluation if there are frequent attacks of abdominal pain,
loss of normal body weight, and other findings showing continuous
pancreatic insufficiency between acute attacks; a 30-percent evaluation
if the condition is moderately severe, with at least 4-7 typical
attacks of abdominal pain per year with good remission between attacks;
and a 10-percent evaluation if there is at least one recurring attack
of typical severe abdominal pain in the past year. We propose to
evaluate pancreatitis on the basis of similar criteria, but to remove
the indefinite adjectives ``frequent,'' ``severe,'' and ``moderately
severe'' in favor of more objective criteria.
We propose a 100-percent evaluation if all of the following are
present: daily or near-daily debilitating attacks of pancreatitis (to
be defined in a note) with few pain-free intermissions; two or more
signs of pancreatic insufficiency (such as steatorrhea, diabetes,
malabsorption, diarrhea, and malnutrition); and unresponsive to medical
treatment. We propose a 60-percent evaluation if the following is
present: seven or more documented attacks of pancreatitis per year with
at least one sign of pancreatic insufficiency (such as steatorrhea,
diabetes, malabsorption, diarrhea, or malnutrition) between acute
attacks. We propose a 30-percent evaluation if any of the following is
present: three to six documented attacks of pancreatitis per year with
at least one sign of pancreatic insufficiency (such as steatorrhea,
diabetes, malabsorption, diarrhea, or malnutrition) between acute
attacks; minimum evaluation following partial pancreatectomy, if
symptomatic and requiring continuous treatment with prescription
medication; or minimum evaluation following total pancreatectomy. We
propose a 10-percent evaluation for one or two documented attacks of
pancreatitis per year, and a zero-percent evaluation for partial
pancreatectomy, if asymptomatic and not requiring continuous treatment
with prescription medication. We are proposing to add the zero-percent
evaluation level for asymptomatic partial pancreatectomy, since it
might not be clear to raters what the evaluation would be in this case,
and as recommended by our consultants.
Total pancreatectomy is disabling in that it requires the
administration of pancreatic enzymes and insulin (``Textbook of
Surgery'' 1096 (David C. Sabiston, Jr., M.D., ed., 14th ed. 1991)),
but, according to our consultants, a partial pancreatectomy without
residual symptoms and not requiring ongoing medical treatment is not
disabling. These criteria are generally in accord with the suggestions
of our consultants and are more objective and measurable than the
current criteria. They would, therefore, promote consistent
evaluations.
Including information about pancreatectomy in the criteria
themselves makes the current note on that subject (note two under
current diagnostic code 7347) unnecessary, and we propose to delete it.
Current note one under diagnostic code 7347 states, ``Abdominal pain in
this condition must be confirmed as resulting from pancreatitis by
appropriate laboratory and clinical studies.'' We propose to retain
that note, but to edit it, and to add a paragraph describing the signs
and symptoms of an attack of pancreatitis. Note one would say that for
purposes of evaluation under diagnostic code 7347, an attack of
pancreatitis means abdominal pain, often very severe, and sometimes
radiating through to the back, with any combination of nausea,
vomiting, anorexia (lack or loss of appetite), fever, and abdominal
tenderness and swelling. (Merck, 1129 and http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/index.htm#acute,
National Digestive Diseases Information Clearinghouse, February 2004).
These symptoms must be confirmed as resulting from pancreatitis by
appropriate laboratory and clinical studies.
We propose to add a second note directing raters to evaluate
complications, such as diabetes mellitus, external gastrointestinal
fistula, and malabsorption, separately under an appropriate diagnostic
code, as
[[Page 39176]]
long as the same findings are not used to support more than one
evaluation.
Pyloroplasty With Vagotomy or Gastroenterostomy With Vagotomy
(Diagnostic Code 7348)
Vagotomy with pyloroplasty or gastroenterostomy, diagnostic code
7348, is currently evaluated at 40, 30 or 20 percent. A 40-percent
evaluation is assigned if there are demonstrably confirmative
postoperative complications of stricture or continuing gastric
retention; a 30-percent evaluation if there are symptoms and a
confirmed diagnosis of alkaline gastritis, or of confirmed persisting
diarrhea; and a 20-percent evaluation if there is recurrent ulcer with
incomplete vagotomy. There is also a note directing raters to evaluate
recurrent ulcer following complete vagotomy under diagnostic code 7305
(duodenal ulcer), with a minimum evaluation of 20 percent, and to rate
dumping syndrome under diagnostic code 7308 (postgastrectomy
syndromes). We propose to direct that this condition be evaluated as
duodenal ulcer (diagnostic code 7305); gastritis (diagnostic code
7307); postgastrectomy syndromes (diagnostic code 7308); or gastric
emptying disorders (diagnostic code 7309), depending upon symptoms and
findings, in order to provide a wide range of objective evaluation
criteria appropriate to the numerous signs and symptoms that may result
from this disability, and to assure more consistent evaluations. This
is in accord with recommendations by our consultants. With the
directions for using this broader range of evaluation criteria, the
note is not necessary, and we propose to remove it. In addition, since
the major impairments from these conditions are ordinarily due to the
gastric surgery, or to the combined effects of gastric surgery and
vagotomy, rather than primarily due to the vagotomy, we propose to
change the title to ``pyloroplasty with vagotomy or gastroenterostomy
with vagotomy'' to indicate this.
Consultant-Recommended Conditions To Be Added
Our consultants suggested adding several conditions to the rating
schedule--gastrointestinal hemorrhage, non-ulcerative dyspepsia, and
porto-systemic shunting. Our experience has shown that these conditions
do not occur commonly enough to warrant inclusion. Furthermore, the
first two are signs or symptoms rather than diseases or injuries, and
they may not be appropriate in the schedule for that reason. When
necessary, digestive conditions not listed in the rating schedule can
be evaluated under analogous codes.
Proposed Conditions To Be Added
We do propose to add four commonly occurring digestive conditions
to the rating schedule: Bowel stricture, as diagnostic code 7349,
colostomy or ileostomy, as diagnostic code 7350, pancreatic transplant,
as diagnostic code 7352, and malabsorption syndrome, as diagnostic code
7353, as described below.
Bowel Stricture (Diagnostic Code 7349)
Currently, the only evaluation criteria in the rating schedule for
stricture of the bowel are those provided under diagnostic code 7333,
stricture of the rectum and anus. We are proposing to delete stricture
of the rectum from diagnostic code 7333, as recommended by our
consultants, and instead provide a new diagnostic code, diagnostic code
7349, ``Bowel stricture,'' for the evaluation of stricture of the bowel
at any level, including the rectum. This would remove the need to
evaluate a bowel stricture under an analogous code.
We propose to establish evaluation levels of 60, 30, and 10 percent
for bowel strictures. These levels are the same as those we are
proposing for peritoneal adhesions (Diagnostic Code 7301), and the
evaluation criteria are also almost identical, because partial bowel
obstruction due to peritoneal adhesions results in similar signs and
symptoms as bowel stricture. We propose a 60-percent evaluation for six
or more episodes per year of partial obstruction of the bowel
(confirmed by an imaging procedure), with typical signs and symptoms; a
30-percent evaluation for three to five such episodes; and a 10-percent
evaluation for one or two such episodes. As with peritoneal adhesions,
we are proposing to add a note to list the typical signs and symptoms
of bowel stricture. The note would state that they include colicky
abdominal pain and at least one of the following other symptoms:
Abdominal distention, borborygmi (audible rumbling bowel sounds),
nausea, vomiting, and obstipation (severe constipation). These proposed
criteria are specific to the condition, are objective, and are similar
to criteria we are proposing to use to evaluate peritoneal adhesions,
as recommended by our consultants.
Colostomy or Ileostomy (Diagnostic Code 7350)
In the current rating schedule, colostomy is mentioned only under
diagnostic code 7333, stricture of the rectum and anus, where a 100-
percent evaluation is assigned if a colostomy is required for that
condition. Since a colostomy (an opening on the abdominal wall from the
colon) may be required for many conditions, however, and is a common
finding, we propose to establish a separate code, diagnostic code 7350,
for the evaluation of either colostomy or ileostomy (an opening on the
abdominal wall from the ileum), a related and also common condition,
with evaluation criteria specific to these disabilities.
Individuals vary in the extent of disability they experience
following ileostomy or colostomy. For example, following ileostomy,
patients generally return to an active physical life and resume their
previous work, and restriction of their activities may vary from mild
to severe (Yamada, 799). Many patients with a colostomy, and some with
an ileostomy, do not require a bag or appliance (Sabiston, 903; Yamada,
799). Some individuals, however, have persistent infection or other
ostomy problems that may be very disabling. We therefore propose to
base the evaluation on whether or not there is an ostomy complication
and on whether or not the ostomy is continent.
We propose to provide evaluation levels of 100, 60, and 30 percent,
in order to provide a range of appropriate evaluation levels. We
propose a 100-percent evaluation for at least one ostomy complication
(such as infection or signs of irritation of the peristomal area,
prolapse, retraction, or stenosis) that is refractory to treatment; a
60-percent evaluation for incontinence, requiring the use of an
external appliance or absorbent material; and a 30-percent evaluation
if the individual is continent, with no external appliance or absorbent
material required.
Pancreas Transplant (Diagnostic Code 7352)
We propose to add pancreatic transplant as diagnostic code 7352,
because this surgical procedure has been developed since the current
schedule went into effect and is done frequently enough to warrant
inclusion. We propose a 100-percent evaluation following transplant
surgery. We further propose the addition of a note explaining the
requirement of a VA examination one year following hospital discharge.
We propose to provide instructions to evaluate thereafter on residuals,
based on the VA examination, and subject to the provisions of 38 CFR
3.105(e). Any proposed reduction would be based on the examination, and
the notification process could begin only
[[Page 39177]]
after the examination had been reviewed. This gives the claimant
current notice of any proposed action and the opportunity to present
evidence showing that the proposed action should not be taken. We
propose a minimum 30-percent evaluation for pancreatic transplant,
because of the need for long-term immunosuppressive medication and its
associated problems. The evaluation criteria we are proposing are the
same as those used for kidney transplant (diagnostic code 7531) in the
genitourinary section of the rating schedule, because both types of
transplant require similar periods of convalescence and long-term
immunosuppressive therapy following convalescence.
Malabsorption Syndrome (Diagnostic Code 7353)
Malabsorption syndrome (including celiac disease, small bowel
bacterial overgrowth, Whipple's disease (intestinal lipodystrophy), and
fistulous disorders) is a common syndrome that can result from a number
of conditions and result in significant impairment, and we propose to
add it as diagnostic code 7353, with evaluation levels of 100, 60, 30,
and 10 percent. We propose a 100-percent evaluation if total parenteral
(intravenous or intramuscular) nutritional support is required; a 60-
percent evaluation for diarrhea, anemia, weakness, and fatigue
requiring daily (oral) nutritional supplementation, plus parenteral
(intravenous or intramuscular) nutrition for a total of at least 28
days per year; a 30-percent evaluation for diarrhea, weakness, and
fatigue requiring daily (oral) nutritional supplementation, plus
parenteral (intravenous or intramuscular) nutrition for a total of at
least 14 days, but less than 28 days per year; and a 10-percent
evaluation for diarrhea, weakness, and fatigue requiring daily (oral)
nutritional supplementation. These are similar to the criteria proposed
for small bowel resection (diagnostic code 7328) because the effects
are similar. Our consultants recommended that the diagnosis of
malabsorption syndrome be confirmed based on a fecal fat loss of 17mEq
or greater per day. However, this is not the primary diagnostic test
for every type of malabsorption syndrome, and we do not propose to
require it.
Paperwork Reduction Act
This document contains no provisions constituting a collection of
information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).
Regulatory Flexibility Act
The Secretary hereby certifies that this proposed rule would 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. This proposed rule would not affect any small entities.
Only VA beneficiaries could be directly affected. Therefore, pursuant
to 5 U.S.C. 605(b), this proposed rule is exempt from the initial and
final regulatory flexibility analysis requirements of sections 603 and
604.
Executive Order 12866
Executive Order 12866 directs agencies to assess all 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,
and other advantages; distributive impacts; and equity). The Executive
Order classifies a ``significant regulatory action,'' requiring review
by the Office of Management and Budget (OMB), unless OMB waives such
review, as any regulatory action that is likely to result in a rule
that may: (1) Have an annual effect on the economy of $100 million or
more or adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment, public
health or safety, or State, local, or tribal governments or
communities; (2) create a serious inconsistency or otherwise interfere
with an action taken or planned by another agency; (3) materially alter
the budgetary impact of entitlements, grants, user fees, or loan
programs or the rights and obligations of recipients thereof; or (4)
raise novel legal or policy issues arising out of legal mandates, the
President's priorities, or the principles set forth in the Executive
Order.
The economic, interagency, budgetary, legal, and policy
implications of this proposed rule has been examined and it has been
determined to be a significant regulatory action under Executive Order
12866 because it is likely to result in a rule that may raise novel
legal or policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in the Executive Order.
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 an 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.
Catalog of Federal Domestic Assistance Numbers and Titles
The Catalog of Federal Domestic Assistance program numbers and
titles for this proposal are 64.104, Pension for Non-Service-Connected
Disability for Veterans, and 64.109, Veterans Compensation for Service-
Connected Disability.
Signing Authority
The Secretary of Veterans Affairs, or designee, approved this
document 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. John R.
Gingrich, Chief of Staff, Department of Veterans Affairs, approved this
document on March 31, 2011, for publication.
List of Subjects in 38 CFR Part 4
Disability benefits, Pensions, Veterans.
Dated: June 20, 2011.
William F. Russo,
Deputy Director, Office of Regulation Policy & Management, Department
of Veterans Affairs.
For the reasons set forth in the preamble, VA proposes to amend 38
CFR part 4, subpart B, as set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
2. Revise Sec. 4.110 to read as follows:
Sec. 4.110 Dyspepsia.
For purposes of evaluating conditions in Sec. 4.114, ``dyspepsia''
means any combination of the following symptoms: Gnawing or burning
epigastric or substernal pain that may be relieved by food (especially
milk) or antacids, nausea, vomiting, anorexia (lack or loss of
appetite), abdominal bloating, and belching. When there is obstruction
of the outlet of the stomach (gastric outlet obstruction), dyspepsia
may also include symptoms of gastroesophageal reflux (flow of stomach
contents back into the esophagus), borborygmi (audible rumbling bowel
sounds),
[[Page 39178]]
crampy pain, and obstipation (severe constipation).
Sec. 4.110 [Removed and Reserved]
3. Remove and reserve Sec. 4.111.
4. In Sec. 4.112, revise the section heading and add two sentences
at the end of the paragraph to read as follows:
Sec. 4.112 Weight loss and malnutrition.
* * * ``Malnutrition'' means a deficiency state resulting from
insufficient intake of one or multiple essential nutrients or the
inability of the body to absorb, utilize, or retain such nutrients. It
is characterized by failure of the body to maintain normal organ
functions and healthy tissues.
5. Revise Sec. 4.113 to read as follows:
Sec. 4.113 Evaluation of coexisting digestive conditions.
Separately evaluate two or more conditions in Sec. 4.114 only if
the signs and symptoms attributed to each are separable. If they are
not, assign a single evaluation under the diagnostic code that best
allows evaluation of the overall functional impairment resulting from
both conditions.
Authority: (38 U.S.C. 1155)
6. Amend Sec. 4.114 by:
a. Removing the introductory text.
b. Removing diagnostic codes 7315, 7316, 7317, 7318, 7321, 7322,
7337, 7340, and 7342.
c. Revising diagnostic codes 7200 through 7310, 7314 through 7339,
and 7346 through 7348.
d. Adding diagnostic codes 7207, 7349, 7350, 7352, and 7353.
The revisions and additions read as follows:
Sec. 4.114 Schedule of ratings--Digestive system.
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
7200 Residuals of mouth injuries.
7201 Residuals of lip injuries.
7202 Residuals of tongue injuries, including tongue loss.
7203 Esophageal stricture.
7204 Achalasia (cardiospasm) and other motor disorders of the
esophagus (diffuse esophageal spasm, corkscrew esophagus,
nutcracker esophagus, etc.).
7205 Esophageal diverticula, including pharyngoesophageal
(Zenker's), midesophageal, and epiphrenic types.
General Rating Formula for:
Residuals of mouth injuries (diagnostic code 7200),
Residuals of lip injuries (diagnostic code 7201),
Residuals of tongue injuries, including tongue loss
(diagnostic code 7202),
Esophageal stricture (diagnostic code 7203),
Achalasia (cardiospasm) and other motor disorders of the
esophagus (diagnostic code 7204), and
Esophageal diverticulum (diagnostic code 7205):
With any of the following................................ 100
Tube feeding required;
Diet restricted to liquid foods, with substantial weight
loss, malnutrition, and anemia;
Four or more episodes per year of pulmonary aspiration
(with bronchitis, pneumonia, or pulmonary abscess) due
to regurgitation or vomiting; or
Inability to speak clearly enough to be understood.
With any of the following................................ 60
Diet restricted to liquid and soft solid foods, with
substantial weight loss or anemia;
Two to three episodes per year of pulmonary aspiration
(with bronchitis, pneumonia, or pulmonary abscess) due
to regurgitation or vomiting; or
Inability to speak clearly enough to be understood at
least half of the time but not all of the time.
With any of the following................................ 30
Diet restricted to liquid and soft solid foods with minor
weight loss;
Esophageal dilation carried out five or more times per
year;
Daily regurgitation or vomiting;
One episode per year of pulmonary aspiration (with
bronchitis, pneumonia, or pulmonary abscess) due to
regurgitation or vomiting; or
Inability to speak clearly enough to be understood at
times, but less than half of the time;
With any of the following................................ 10
Diet restricted to liquid and soft solid foods;
Esophageal dilation carried out one to four times per
year;
Heartburn (pyrosis) requiring continuous treatment with
prescription medication and at least one of the
following other symptoms: retrosternal chest pain,
difficulty swallowing (dysphagia), or pain during
swallowing (odynophagia);
Partial tongue loss; or
Impaired articulation for some words, but speech
understandable.
Note: Separately evaluate mouth and lip injuries under
diagnostic code 7800 (Burn scar(s) of the head, face, or
neck; scar(s) of the head, face, or neck due to other
causes; or other disfigurement of the head, face, or neck),
if applicable, and combine with an evaluation under this
general rating formula, under the provisions of Sec. 4.25.
7207 Salivary gland (parotid, submandibular, sublingual)
disease other than neoplasm:
Xerostomia (dry mouth) with altered sensation of taste and 20
difficulty with lubrication and mastication of food,
resulting in either weight loss or increase in dental caries
With any of the following................................ 10
Xerostomia (dry mouth) with altered sensation of taste
and difficulty with lubrication and mastication of food,
but without weight loss or increase in dental caries;
Chronic inflammation of salivary gland with pain and
swelling on eating;
One or more salivary calculi; or
Salivary gland stricture.
With either of the following............................. 0
Xerostomia (dry mouth) without difficulty in mastication
of food; or
Painless swelling of salivary gland.
[[Page 39179]]
Note (1): Evaluate facial nerve (cranial nerve VII)
impairment under diagnostic code 8207 (Paralysis of seventh
(facial) cranial nerve), and any disfigurement due to facial
swelling under diagnostic code 7800 (Burn scar(s) of the
head, face, or neck; scar(s) of the head, face, or neck due
to other causes; or other disfigurement of the head, face,
or neck)....................................................
Note (2): Xerostomia (dry mouth) is a common symptom of
Sjogren's syndrome, an autoimmune disorder that also causes
keratoconjunctivitis sicca (dry eyes), and may affect other
parts of the body. Evaluate xerostomia due to Sjogren's
syndrome under diagnostic code 7207, keratoconjunctivitis
sicca under the portion of the rating schedule that
addresses Organs of Special Sense, and the effects of the
syndrome, if any, on other body parts under appropriate
diagnostic codes............................................
7301 Peritoneal adhesions.
Six or more episodes per year of partial obstruction of 60
the bowel (confirmed by X-ray), with typical signs and
symptoms................................................
Three to five episodes per year of partial obstruction of 30
the bowel (confirmed by X-ray), with typical signs and
symptoms................................................
One or two episodes per year of partial obstruction of 10
the bowel (confirmed by X-ray), with typical signs and
symptoms, or in the absence of such episodes, pulling
pain on body movement, if not attributable to another
condition...............................................
Note (1): Evaluation under diagnostic code 7301 requires a
history of abdominal or pelvic surgery, infection,
irradiation, trauma, or other known etiology for peritoneal
adhesions...................................................
Note (2): For purposes of evaluation under diagnostic code
7301 typical signs and symptoms of partial obstruction of
the bowel include colicky abdominal pain, and at least one
of the following other symptoms: abdominal distention,
borborygmi (audible rumbling bowel sounds), nausea,
vomiting, and diarrhea......................................
7304 Gastric ulcer.
7305 Duodenal ulcer or duodenitis.
7306 Marginal (gastrojejunal) ulcer.
General Rating Formula for:
Ulcer Disease (diagnostic code 7304, diagnostic code
7305, and diagnostic code 7306):
With either of the following............................. 100
Substantial weight loss, malnutrition, and anemia due to
gastrointestinal bleeding; or
Requiring hospitalization three or more times per year
for vomiting, refractory pain, gastrointestinal
bleeding, perforation, obstruction, or penetration to
liver, pancreas, or colon.
With either of the following............................. 60
Periodic or constant dyspepsia with substantial weight
loss and anemia due to gastrointestinal bleeding; or
Hospitalization twice per year for vomiting, refractory
pain, gastrointestinal bleeding, perforation,
obstruction, or penetration to liver, pancreas, or
colon.
With either of the following............................. 30
Periodic or constant dyspepsia with at least minor weight
loss; or
Hospitalization once per year for vomiting, refractory
pain, gastrointestinal bleeding, perforation,
obstruction, or penetration to liver, pancreas, or
colon.
Recurring dyspepsia that requires continuous treatment 10
with prescription medication for control................
Note: Evaluation under diagnostic codes 7304, 7305, or 7306
requires that the diagnosis of ulcer disease or duodenitis
be confirmed on at least one occasion by imaging or
endoscopy...................................................
7307 Chronic gastritis (including but not limited to erosive,
hypertrophic, hemorrhagic, bile reflux, alcoholic, and drug-
induced gastritis):
With any of the following................................ 60
Periodic or continuous dyspepsia with anemia due to
gastrointestinal bleeding;
Protein-losing gastropathy with substantial weight loss
and peripheral edema; or
Hospitalization two or more times per year for
gastrointestinal bleeding, intractable vomiting, or
other complication of chronic gastritis.
With either of the following............................. 30
Protein-losing gastropathy with at least minor weight
loss; or
Hospitalization once per year for gastrointestinal
bleeding, intractable vomiting, or other complication of
chronic gastritis.
Dyspepsia that requires continuous treatment with 10
prescription medication.................................
Note (1): Evaluation under diagnostic code 7307 requires that
the diagnosis of chronic gastritis be confirmed on at least
one occasion by endoscopy...................................
Note (2): Evaluate atrophic gastritis, which is a
complication of a number of diseases, including pernicious
anemia, as part of the underlying condition.................
7308 Postgastrectomy syndromes:
Dumping syndrome that occurs after most meals, with 100
substantial weight loss, malnutrition, and anemia.......
Dumping syndrome that occurs after most meals, with 60
substantial weight loss and anemia......................
Dumping syndrome occurring daily or nearly so, despite 30
treatment, with at least minor weight loss..............
Intermittent dumping syndrome (occurring at least three 10
times a week) requiring dietary restrictions............
Note (1): For purposes of evaluation under diagnostic code
7308, the term ``dumping syndrome'' includes symptoms that
are associated with any of the following postgastrectomy
syndromes: early and late types of dumping syndrome,
postgastrectomy diarrhea, and alkaline reflux gastritis.
These symptoms include any combination of weakness,
dizziness, lightheadedness, diaphoresis (sweating),
palpitations, tachycardia, postural hypotension, confusion,
syncope (fainting), nausea, vomiting (often with bile),
diarrhea, steatorrhea (fatty stools), borborygmi (audible
rumbling bowel sounds), abdominal pain, anorexia (lack or
loss of appetite), abdominal bloating, and belching.
Symptoms may occur immediately after eating or up to three
hours later.................................................
Note (2): Separately evaluate complications, such as
osteomalacia, under an appropriate diagnostic code..........
7309 Gastric emptying disorders (including gastroparesis
(delayed gastric emptying), and pyloric, gastric, and other
motility disturbances):
Daily or near-daily signs and symptoms with substantial 100
weight loss and malnutrition............................
Periodic or daily or near-daily signs and symptoms with 60
substantial weight loss.................................
Periodic signs and symptoms with minor weight loss....... 30
Periodic signs and symptoms, without weight loss, but 10
requiring continuous treatment with prescription
medication..............................................
Note: For purposes of evaluation under diagnostic code 7309,
the signs and symptoms of gastric emptying disorders include
epigastric pain or fullness and at least one of the
following other symptoms: anorexia (lack or loss of
appetite), nausea, vomiting, gastroesophageal reflux, early
satiety (feeling that hunger and thirst are satisfied), and
abdominal bloating..........................................
7310 Residuals of injury of the stomach:
[[Page 39180]]
Evaluate as peritoneal adhesions (diagnostic code 7301),
or, if the injury required a gastric resection, as
postgastrectomy syndromes (diagnostic code 7308).
* * * * * * *
7314 Biliary tract disease or injury (chronic cholecystitis,
cholelithiasis, choledocholithiasis, chronic cholangitis,
status post-cholecystectomy, gall bladder or bile duct
injury, biliary dyskinesia, cholesterolosis, polyps of gall
bladder, sclerosing cholangitis, stricture or infection of
the bile ducts, choledochal cyst):
With any of the following................................ 100
Near-constant debilitating attacks of biliary tract
disease or injury that are refractory to medical or
surgical treatment;
Liver failure; or
Hospitalization three or more times per year for biliary
tract disease or injury.
With either of the following............................. 60
Six or more attacks of biliary tract disease or injury
per year, partially responsive to treatment; or
Hospitalization two times per year for biliary tract
disease or injury.
With either of the following............................. 30
Three to five attacks of biliary tract disease or injury
per year; or
Hospitalization once per year for biliary tract disease
or injury.
With either of the following............................. 10
One or two attacks of biliary tract disease or injury per
year; or
Intermittent biliary tract pain occurring at least
monthly, despite medical treatment.
Note (1): For purposes of evaluation under diagnostic code
7314, attacks of biliary tract disease or injury include any
combination of such signs and symptoms as abdominal pain
(including biliary colic), dyspepsia, jaundice, anorexia
(lack or loss of appetite), nausea, vomiting, chills, and
fever.......................................................
Note (2): Evaluation under diagnostic code 7314 requires that
the diagnosis of any of these conditions be confirmed by X-
ray or other imaging procedure, laboratory findings, or
other objective evidence....................................
Note (3): Separately evaluate peritoneal adhesions
(diagnostic code 7301), if applicable, and combine (under
the provisions of Sec. 4.25) with an evaluation under
diagnostic code 7314, as long as the same findings are not
used to support more than one evaluation (see Sec. 4.14)..
Note (4): Evaluate the cirrhotic phase of sclerosing
cholangitis under diagnostic code 7312 (cirrhosis of the
liver)......................................................
7319 Irritable bowel syndrome (irritable colon, spastic
colitis, mucous colitis):
Daily or near-daily disturbances of bowel function 30
(diarrhea, or alternating diarrhea and constipation),
bloating, and abdominal cramping or pain, refractory to
medical treatment.......................................
Disturbances of bowel function (diarrhea, or alternating 10
diarrhea and constipation), bloating, and abdominal
cramping or pain that occur three or more times a month
and that respond partially to medical treatment.........
7323 Ulcerative colitis:
With either of the following............................. 100
Malnutrition, substantial weight loss, anemia, and
general debility with multiple attacks of colitis per
year, with bloody diarrhea, abdominal or rectal pain,
fever, and malaise.
Hospitalization three or more times per year for
complications such as hemorrhage, dehydration,
obstruction, fulminant (sudden and intense) colitis,
toxic megacolon (a severe distention of the colon that
can be life threatening), or perforation.
With either of the following............................. 60
Substantial weight loss and anemia, with multiple attacks
of colitis per year, with bloody diarrhea, abdominal or
rectal pain, fever, and malaise; or
Hospitalization two times per year for complications such
as hemorrhage, dehydration, obstruction, fulminant
(sudden and intense) colitis, toxic megacolon (a severe
distention of the colon that can be life threatening),
or perforation.
With either of the following............................. 30
Three or more attacks of colitis (each lasting 5 or more
days) per year, with diarrhea with blood, pus, or mucus,
and abdominal or rectal pain; or
Hospitalization one time per year for complications such
as hemorrhage, dehydration, obstruction, fulminant
(sudden and intense) colitis, toxic megacolon (a severe
distention of the colon that can be life threatening),
or perforation.
With either of the following............................. 10
One or two attacks of colitis (each lasting 5 or more
days) per year with diarrhea with blood, pus, or mucus,
and abdominal or rectal pain; or
Continuous treatment with prescription medication either
to control symptoms or to maintain remission.
Note (1): Separately evaluate other complications, such as
uveitis, ankylosing spondylitis, and sclerosing cholangitis,
under an appropriate diagnostic code........................
Note (2): If there has been a colon resection, evaluate under
diagnostic codes 7350 (colostomy or ileostomy) and 7329
(resection of large intestine), as applicable, and combine
the evaluations under the provisions of Sec. 4.25, as long
as the same findings are not used to support more than one
evaluation (see Sec. 4.14)................................
7324 Parasitic infections of the intestinal tract:
Daily diarrhea (occurring more than three times per day) 30
and abdominal pain, with at least minor weight loss.....
Diarrhea and abdominal pain requiring continuous 10
treatment with prescription medication for control......
Note: If malabsorption is present, evaluate instead under
diagnostic code 7353 (malabsorption syndrome), if doing so
would result in a higher evaluation.........................
7325 Chronic diarrhea of unknown etiology:
Five or more watery bowel movements occurring daily, 60
refractory to medical treatment, and with three or more
episodes per year of fluid and electrolyte imbalance
requiring parenteral (intravenous or intramuscular)
hydration...............................................
Five or more watery bowel movements occurring daily, 30
partially responsive to medical treatment, and with one
or two episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or
intramuscular) hydration................................
Requiring continuous treatment with prescription 10
medication for control..................................
7326 Crohn's disease:
With either of the following............................. 100
Multiple attacks or flareups of Crohn's disease per year
with abdominal pain or tenderness, diarrhea, fever,
anorexia (lack or loss of appetite), and fatigue plus
malnutrition, substantial weight loss, hypoalbuminemia,
and anemia; or
[[Page 39181]]
Hospitalization three or more times per year for
complications such as abscess, stricture, obstruction,
or fistula.
With any of the following................................ 60
Multiple attacks or flareups of Crohn's disease per year
with abdominal pain or tenderness, diarrhea, fever,
anorexia (lack or loss of appetite), and fatigue plus
substantial weight loss and anemia;
Hospitalization two times per year for recurrent
complications such as abscess, stricture, obstruction,
or fistula; or
Constant or near-constant treatment with high dose
systemic (oral or parenteral [intravenous or
intramuscular]) corticosteroids.
With any of the following................................ 30
Three or more attacks or flareups of Crohn's disease per
year with abdominal pain or tenderness, diarrhea, fever,
anorexia (lack or loss of appetite), and fatigue, plus
at least minor weight loss;
Hospitalization one time per year for complications such
as abscess, stricture, obstruction, or fistula; or
Three or more (but not constant) courses of treatment per
year with high dose systemic (oral or parenteral
[intravenous or intramuscular]) corticosteroids.
With any of the following................................ 10
One or two attacks or flareups of Crohn's disease per
year with abdominal pain or tenderness, diarrhea, and
fever;
One or two courses of treatment per year with high dose
systemic (oral or parenteral [intravenous or
intramuscular]) corticosteroids;
Continuous treatment with prescription medication other
than high dose systemic (oral or parenteral [intravenous
or intramuscular]) corticosteroids.
Note (1): Separately evaluate complications, such as external
gastrointestinal fistula, arthritis, episcleritis
(inflammation of the outer layers of the sclera of the eye),
etc., under an appropriate diagnostic code as long as the
same findings are not used to support more than one
evaluation (see Sec. 4.14)................................
Note (2): Evaluate under diagnostic code 7350 (colostomy or
ileostomy) if an ostomy is present, and under diagnostic
code 7328 (resection of the small intestine) or 7329
(resection of large intestine), if applicable, as long as
the same findings are not used to support more than one
evaluation (see Sec. 4.14)................................
7327 Diverticulitis:
With either of the following............................. 100
Near-constant signs and symptoms of diverticulitis, with
abdominal pain and tenderness, fever, and irregular
defecation (constipation, diarrhea, or alternating
constipation and diarrhea); or
Hospitalization at least three times per year for
complications such as abscess, perforation, obstruction,
or fistula.
With any of the following................................ 60
Six or more attacks of diverticulitis per year with
abdominal pain and tenderness, fever, and irregular
defecation (constipation, diarrhea, or alternating
constipation and diarrhea), requiring outpatient
treatment with a course of antibiotics, bed rest, and a
liquid diet;
Hospitalization two times per year for complications such
as abscess, perforation, obstruction, or fistula; or
Hospitalization three or more times per year for acute
diverticulitis requiring intravenous antibiotics.
With any of the following................................ 30
Three to five attacks of diverticulitis per year with
abdominal pain and tenderness, fever, and irregular
defecation (constipation, diarrhea, or alternating
constipation and diarrhea), requiring outpatient
treatment with a course of antibiotics, bed rest, and a
liquid diet;
Hospitalization one time per year for complications such
as abscess, perforation, obstruction, or fistula; or
Hospitalization once or twice per year for acute
diverticulitis requiring intravenous antibiotics.
With one or two attacks of diverticulitis per year with 10
abdominal pain and tenderness, fever, and irregular
defecation (constipation, diarrhea, or alternating
constipation and diarrhea), requiring a course of
antibiotics.............................................
Note: Evaluate under diagnostic code 7350 (colostomy or
ileostomy) if an ostomy is present, and under diagnostic
code 7329 (resection of large intestine), if applicable, as
long as the same findings are not used to support more than
one evaluation (see Sec. 4.14)............................
7328 Resection of small intestine:
Requiring total parenteral (intravenous or intramuscular) 100
nutritional support.....................................
Diarrhea, weakness, fatigue, abdominal cramps, and 60
bloating, with anemia, requiring daily (oral)
nutritional supplementation, plus parenteral
(intravenous or intramuscular) nutrition for a total of
at least 28 days per year...............................
Diarrhea, weakness, fatigue, abdominal cramps, and 30
bloating requiring daily (oral) nutritional
supplementation, plus parenteral (intravenous or
intramuscular) nutrition for a total of at least 14
days, but less than 28 days per year....................
Diarrhea, weakness, fatigue, abdominal cramps, and 10
bloating requiring daily (oral) nutritional
supplementation.........................................
Note: Separately evaluate peritoneal adhesions (diagnostic
code 7301), if applicable, as long as the same findings are
not used to support an evaluation both under diagnostic code
7301 and under diagnostic code 7328 (see Sec. 4.14).......
7329 Resection of large intestine:
Multiple daily episodes of diarrhea and abdominal pain 100
that are refractory to treatment, plus at least two
hospitalizations per year for complications such as
obstruction, fistula, or abscess........................
Multiple attacks of diarrhea and abdominal pain per year 60
requiring medical treatment, plus at least one
hospitalization per year for complications such as
obstruction, fistula, or abscess........................
Four or more attacks of diarrhea and abdominal pain per 30
year requiring medical treatment........................
Two or three attacks of diarrhea and abdominal pain per 10
year requiring medical treatment........................
Note (1): Separately evaluate peritoneal adhesions
(diagnostic code 7301), if applicable, and combine (under
the provisions of Sec. 4.25) with an evaluation under
diagnostic code 7329, as long as the same findings are not
used to support more than one evaluation (see Sec. 4.14)..
Note (2): Evaluate under diagnostic code 7350 (colostomy or
ileostomy), if applicable, and combine (under the provisions
of Sec. 4.25) with an evaluation under diagnostic code
7329, as long as the same findings are not used to support
more than one evaluation (see Sec. 4.14)..................
7330 External gastrointestinal fistula (including biliary,
pancreatic, esophageal, gastric, and intestinal fistulas):
Constant or near-constant copious discharge that cannot 100
be contained, and with any of the following.............
Requiring total parenteral (intravenous or intramuscular)
nutritional support;
Malnutrition;
Seven or more episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or
intramuscular) hydration; or
[[Page 39182]]
Two or more episodes per year of sepsis (a serious and
sometimes life-threatening infection with a widespread
inflammatory response).
Constant or near-constant, copious discharge that cannot 60
be contained, and with any of the following.............
Persistent skin breakdown, despite treatment;
Five or six episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or
intramuscular) hydration; or
One episode per year of sepsis (a serious and sometimes
life-threatening infection with a widespread
inflammatory response).
Constant or intermittent discharge with either of the 30
following...............................................
Six or more episodes per year of skin breakdown that
require treatment; or
Two to four episodes per year of fluid and electrolyte
imbalance requiring parenteral (intravenous or
intramuscular) hydration.
Constant or intermittent discharge with either of the 10
following...............................................
At least two, but less than six, episodes per year of
skin breakdown requiring treatment;
One episode per year of fluid and electrolyte imbalance
requiring parenteral (intravenous or intramuscular)
hydration.
Note: Evaluate internal gastrointestinal fistulas (fistulas
that drain from one area of the gastrointestinal tract to
another) under the criteria for malabsorption (diagnostic
code 7353) or other appropriate condition, depending on the
particular findings.........................................
7331 Tuberculous peritonitis:
Active................................................... 100
Inactive: Evaluate in accordance with Sec. Sec. 4.88c
or 4.89, whichever is applicable.
7332 Impaired control of the anal sphincter (anal
incontinence):
Complete inability to control solid and liquid feces..... 100
Daily fecal soiling and complete inability to control 60
liquid feces............................................
Fecal soiling that, although less than daily, is frequent 30
enough or extensive enough to require daily wearing of
absorbent material......................................
Fecal soiling that is intermittent, and not frequent 10
enough or extensive enough to require daily wearing of
absorbent material......................................
Note: Evaluate under diagnostic code 7350 (colostomy or
ileostomy), if an ostomy is present.........................
7333 Stricture of the anus:
Inability to open or completely close the anus, with 100
complete inability to control liquid or solid feces.....
Reduction of the lumen by at least 50 percent, with pain 60
and prolonged straining during defecation, and complete
inability to control liquid feces.......................
Reduction of the lumen, but by less than 50 percent, with 30
straining during defecation, and fecal incontinence that
requires daily wearing of absorbent material............
Reduction of the lumen, with fecal soiling that is not 10
frequent enough or extensive enough to require daily
wearing of absorbent material...........................
Note: Evaluate under diagnostic code 7350 (colostomy or
ileostomy), if an ostomy is present.........................
7334 Prolapse of rectum:
Persistent prolapse with complete inability to control 100
liquid or solid feces...................................
Intermittent prolapse (occurring three or more times 60
weekly): with complete inability to control liquid or
solid feces during periods of prolapse..................
Intermittent prolapse (occurring three or more times 30
weekly): without complete inability to control liquid or
solid feces during periods of prolapse, but with
difficulty in bowel evacuation and fecal soiling that is
frequent enough or extensive enough to require daily
wearing of absorbent material...........................
Intermittent prolapse with difficulty in bowel evacuation 10
and fecal soiling that is not frequent enough or
extensive enough to require daily wearing of absorbent
material................................................
7335 Fistula in ano (anorectal fistula, anorectal abscess):
Constant or near-constant abscesses with drainage and 100
pain, refractory to medical and surgical treatment......
Four or more abscesses (each lasting a week or more) per 60
year with drainage and pain.............................
Three or more abscesses (each lasting less than a week) 30
per year with drainage and pain.........................
One or two abscesses (each lasting less than a week) per 10
year with drainage and pain, or; fistula with pain and
discharge but without associated abscesses..............
7336 Hemorrhoids:
With either of the following............................. 20
Persistent bleeding with anemia; or
Permanently prolapsed internal hemorrhoids with three or
more episodes per year of thrombosis.
With either of the following............................. 10
Permanently or intermittently prolapsed internal
hemorrhoids with one or two episodes per year of
thrombosis; or
External hemorrhoids with three or more episodes per year
of Thrombosis.
7338 Hernia, inguinal or femoral (both post-operative
recurrent and non-operated):
Hernia with all of the following......................... 60
Greatest diameter is 15 centimeters (5.91 inches) or
more;
Cannot be corrected by surgery; and
Requires support but is not well supported by external
devices or is not easily reducible.
Hernia with all of the following......................... 30
Greatest diameter is less than 15 centimeters (5.91
inches);
Cannot be corrected by surgery; and
Requires support but is not well supported by external
devices or is not easily reducible.
Hernia with all of the following......................... 10
Of any size;
Can be corrected by surgery;
Requires support and is supportable by external devices;
and
Easily reducible.
Note: If there are bilateral hernias, evaluate each hernia
separately, and combine (under the provisions of Sec.
4.25).......................................................
7339 Ventral (incisional) hernia, and other abdominal hernias
postoperative:
Hernia with both of the following........................ 100
Greatest diameter is 30 centimeters (11.81 inches) or
more; and
Refractory to further operative correction due to
extensive loss of muscular and fascial support.
[[Page 39183]]
Hernia with both of the following........................ 60
Greatest diameter is 20 centimeters (7.87 inches) or
more; and
Requires support but is not well supported by external
devices or not easily reducible.
Hernia with both of the following........................ 30
Greatest diameter is less than 20 centimeters (7.87
inches); and
Requires support but is not well supported by external
devices or not easily reducible.
Hernia with all of the following......................... 10
Of any size;
Requires support and is supportable by external devices;
and
Easily reducible.
* * * * * * *
7346 Gastroesophageal reflux disease (GERD), hiatal hernia,
esophagitis, lower esophageal (Schatzki's) ring:
Erosive reflux esophagitis (inflammation and ulceration 60
of the esophagus due to reflux of gastric contents into
the esophagus) confirmed by endoscopy, imaging, or other
laboratory procedure, with at least one of the following
Anemia and substantial weight loss;
One or more episodes per year of gastrointestinal
hemorrhage; or
Two or more episodes per year of pulmonary aspiration
(with bronchitis, pneumonia, or pulmonary abscess) due
to regurgitation.
Erosive reflux esophagitis (inflammation and ulceration 30
of the esophagus due to reflux of gastric contents into
the esophagus) confirmed by endoscopy, imaging, or other
laboratory procedure, with either of the following......
Symptoms such as pyrosis (heartburn), retrosternal or arm
or shoulder pain, regurgitation of gastric contents into
the mouth, dysphagia (difficulty swallowing), and
odynophagia (pain during swallowing) that are
intractable despite treatment; or
One episode per year of pulmonary aspiration (with
bronchitis, pneumonia, or pulmonary abscess) due to
regurgitation.
Symptoms such as pyrosis (heartburn), retrosternal or arm 10
or shoulder pain, regurgitation of gastric contents into
the mouth, dysphagia (difficulty swallowing), and
odynophagia (pain during swallowing) that are largely
controlled by continuous treatment with prescription
medication..............................................
Intermittent symptoms such as pyrosis (heartburn), 0
retrosternal or arm or shoulder pain, regurgitation of
gastric contents into the mouth, dysphagia (difficulty
swallowing), and odynophagia (pain during swallowing)
that respond to dietary changes, lifestyle changes, or
treatment with antacids or other nonprescription
medications.............................................
Note: Evaluate esophageal strictures under the General Rating
Formula for Residuals of mouth injuries (7200), Residuals of
lip injuries (7201), Residuals of tongue injuries, including
tongue loss (7202), Esophageal stricture (7203), Achalasia
(cardiospasm) and other motor disorders of the esophagus
(7204), and Esophageal diverticula (7205)...................
7347 Pancreatitis, total pancreatectomy, and partial
pancreatectomy:
With all of the following................................ 100
Daily or near-daily debilitating attacks of pancreatitis
with few pain-free intermissions;
Two or more signs of pancreatic insufficiency (such as
steatorrhea, diabetes, malabsorption, diarrhea, and
malnutrition); and
Unresponsive to medical treatment.
With the following....................................... 60
Seven or more documented attacks of pancreatitis per year
with at least one sign of pancreatic insufficiency (such
as steatorrhea, diabetes, malabsorption, diarrhea, or
malnutrition) between acute attacks.
With any of the following................................ 30
Three to six documented attacks of pancreatitis per year
with at least one sign of pancreatic insufficiency (such
as steatorrhea, diabetes, malabsorption, diarrhea, or
malnutrition) between acute attacks;
Minimum evaluation following partial pancreatectomy, if
symptomatic and requiring continuous treatment with
prescription medication; or
Minimum evaluation following total pancreatectomy.
One or two documented attacks of pancreatitis per year... 10
Partial pancreatectomy, if asymptomatic and not requiring 0
continuous treatment with prescription medication.......
Note (1): For purposes of evaluation under diagnostic code
7347, an attack of pancreatitis means abdominal pain, often
very severe, and sometimes radiating through to the back,
with any combination of nausea, vomiting, anorexia (lack or
loss of appetite), fever, and abdominal tenderness and
swelling....................................................
Evaluation under diagnostic code 7347 requires that the
attacks of abdominal pain and other symptoms be
confirmed by appropriate laboratory and clinical studies
as resulting from pancreatitis
Note (2): Separately evaluate complications, such as diabetes
mellitus, external gastrointestinal fistula, and
malabsorption, as long as the same findings are not used to
support more than one evaluation (see Sec. 4.14)..........
7348 Pyloroplasty with vagotomy or gastroenterostomy with
vagotomy:
Depending upon symptoms and findings, evaluate as:
duodenal ulcer (diagnostic code 7305); gastritis
(diagnostic code 7307); postgastrectomy syndromes
(diagnostic code 7308); or gastric emptying disorders
(diagnostic code 7309).
7349 Bowel stricture:
Six or more episodes per year of partial obstruction of 60
the bowel (confirmed by an imaging procedure), with
typical signs and symptoms..............................
Three to five episodes per year of partial obstruction of 30
the bowel (confirmed by an imaging procedure), with
typical signs and symptoms..............................
One or two episodes per year of partial obstruction of 10
the bowel (confirmed by an imaging procedure), with
typical signs and symptoms..............................
Note: For purposes of evaluation under diagnostic code 7349,
typical signs and symptoms of bowel stricture include
colicky abdominal pain, and at least one of the following
other symptoms: abdominal distention, borborygmi (audible
rumbling bowel sounds), nausea, vomiting, and obstipation
(severe constipation).......................................
7350 Colostomy or ileostomy:
With at least one ostomy complication (such as infection 100
or signs of irritation of the peristomal area, prolapse,
retraction, or stenosis) that is refractory to treatment
Incontinent, requiring the use of an external appliance 60
or absorbent material...................................
Continent, not requiring external appliance or absorbent 30
material................................................
[[Page 39184]]
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7352 Pancreas transplant:
Following transplant surgery............................. 100
Thereafter, evaluate on residuals. Minimum evaluation 30
percent.
Note: The 100 percent rating shall be assigned as of the date
of hospital admission for transplant surgery and shall
continue with a mandatory VA examination one year following
hospital discharge. Any change in evaluation shall be
subject to the provisions of Sec. 3.105(e) of this chapter
7353 Malabsorption syndrome (including celiac disease, small
bowel bacterial overgrowth, Whipple's disease (intestinal
lipodystrophy), and fistulous disorders):
Requiring total parenteral (intravenous or intramuscular) 100
nutritional support.....................................
Diarrhea, anemia, weakness, and fatigue requiring daily 60
(oral) nutritional supplementation, plus parenteral
(intravenous or intramuscular) nutrition for a total of
at least 28 days per year...............................
Diarrhea, weakness, and fatigue requiring daily (oral) 30
nutritional supplementation plus parenteral (intravenous
or intramuscular) nutrition for a total of at least 14
days, but less than 28 days per year....................
Diarrhea, weakness, and fatigue requiring daily (oral) 10
nutritional supplementation.............................
* * * * * * *
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[FR Doc. 2011-15698 Filed 7-1-11; 8:45 am]
BILLING CODE 8320-01-P