[Federal Register Volume 59, Number 11 (Tuesday, January 18, 1994)] [Unknown Section] [Page 0] From the Federal Register Online via the Government Publishing Office [www.gpo.gov] [FR Doc No: 94-1045] [[Page Unknown]] [Federal Register: January 18, 1994] ======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF VETERANS AFFAIRS 38 CFR Part 4 RIN 2900-AE11 Schedule for Rating Disabilities; Genitourinary System Disabilities AGENCY: Veterans Affairs. ACTION: Final regulation. ----------------------------------------------------------------------- SUMMARY: The Department of Veterans Affairs (VA) has amended its Schedule for Rating Disabilities of the Genitourinary System. This amendment is based on a General Accounting Office (GAO) study noting that there has been no comprehensive review of the rating schedule since 1945, and recommending that such a review be conducted. The effect of this action is to update the genitourinary portion of the rating schedule to ensure that it uses current medical terminology, unambiguous criteria, and that it reflects medical advances which have occurred since the last review. DATES: This amendment is effective February 17, 1994. FOR FURTHER INFORMATION CONTACT: Bob Seavey, Consultant, Regulations Staff, Compensation and Pension Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 233-3005. SUPPLEMENTARY INFORMATION: In December 1988, the General Accounting Office (GAO) recommended that VA prepare a plan for a comprehensive review of the rating schedule and, based on the results, revise the medical criteria accordingly. As part of the process to implement these recommendations, VA published a proposal to amend 38 CFR 4.115 and 4.115a in the Federal Register of December 2, 1991 (56 FR 61216-20). Interested persons were invited to submit written comments, suggestions or objections on or before January 2, 1992. We received comments from the Veterans of Foreign Wars, the Disabled American Veterans, the Paralyzed Veterans of America, and VA employees. We have made a number of editorial changes, primarily of syntax and punctuation, throughout the final rule. These changes are intended to clarify the rating criteria and represent no substantive amendment. Generic terms such as ``severe,'' ``moderate,'' and ``mild,'' which preceded various evaluation criteria in the proposed regulations, have been removed. Rather than helping to explain or clarify the specific evaluation criteria which they precede, these terms inject an element of ambiguity not otherwise present. Under diagnostic code 7524, we have deleted the phrase ``other than undescended or congenitally undeveloped'' for the noncompensable evaluation criteria since the NOTE following adequately explains that an undescended or congenitally undeveloped testis is not ratable. We proposed that Sec. 4.115 be amended to allow separate evaluation of coexisting ``heart disease'' in the event of an absent kidney, or when chronic renal disease has progressed to the point where regular dialysis is required. One commenter pointed out that in addition to heart disease, hypertension is often manifested in cases of renal disease, but that the proposed regulatory language would preclude a separate evaluation for hypertension. He suggested that we substitute the term ``cardiovascular disease'' for ``heart disease.'' Although we agree that this provision should apply to hypertension as well as heart disease, we believe that the term ``cardiovascular'' is too broad since it might be interpreted to include cardiovascular conditions unrelated to renal dysfunction. We have therefore amended Sec. 4.115 to specify that coexisting heart disease or hypertension may be separately evaluated in the absence of one kidney or when the claimant requires dialysis. Our proposed rating formula for renal dysfunction under Sec. 4.115a included a requirement at the 100 percent level for blood urea nitrogen (BUN) and creatinine thresholds of more than 100mg% and 10mg%, respectively. One commenter felt that the proposed requirements are too high and suggested that 80mg% and 8mg% would be more appropriate. Upon further review, we have concluded that measurements over 80/8mg% suggest a need for dialysis and would therefore be a more appropriate threshold. We have accordingly amended the criteria for a 100 percent evaluation in Sec. 4.115a. In keeping with that change, we have also amended the ranges of BUN and creatinine readings required for an 80 percent evaluation to 40-80mg% and 4-8mg%, respectively. Two commenters felt that the word ``invalidism'' in the proposed criteria for the 100 and 80 percent levels for renal dysfunction is inappropriate because it is archaic, too subjective, and in fact suggests a level of severity more consistent with entitlement to special monthly compensation. VA agrees, and has substituted the phrase ``precluding more than sedentary activity'' for the 100 percent evaluation, and the phrase ``generalized poor health characterized by * * *'' for the 80 percent evaluation. Under the 60 percent evaluation level for renal dysfunction, we had proposed that qualifying manifestations of hypertension be referred to as ``moderate hypertension'' whereas under the 30 percent level we had proposed that hypertension be ``minimally compensable under diagnostic code 7101.'' One commenter recommended that hypertension be described consistently in terms of diagnostic code 7101 throughout the criteria for renal dysfunction. We agree. Such a change would promote not only a clearer understanding of the rule, but internal consistency within the rating schedule as well. We have therefore modified the criteria for a 60 percent evaluation to require hypertension at least 40 percent disabling under diagnostic code 7101, for a 30 percent evaluation to require hypertension at least 10 percent disabling under diagnostic code 7101, and the zero percent evaluation to include hypertension non- compensable under diagnostic code 7101. One commenter felt that either albumin and casts with a history of acute nephritis or renal dysfunction with mild hypertension warrants a 10 percent evaluation rather than the zero percent we had proposed under the criteria for renal dysfunction. We do not concur. Albuminuria and granular casts are clinical findings which may or may not indicate active kidney disease, but which themselves are not inherently disabling. Since the level of compensation is determined primarily by the extent to which a condition is disabling, and since an asymptomatic condition, or combination of asymptomatic conditions, imposing no discernible industrial impairment does not warrant a compensable evaluation, we find no reason to assign these conditions a compensable evaluation in the absence of chronic kidney disease or hypertension which is compensable under diagnostic code 7101. Two commenters questioned the reduction of the evaluation for loss of a single kidney from 30 percent to zero percent disabling. Although long-term renal function returns to near normal due to hypertrophy of the remaining kidney, the significant anatomical alteration caused by removal of a kidney, the resulting surgical scar, and the precautions which must be taken to protect the remaining kidney, could reasonably be expected to prevent a veteran from engaging in certain, but by no means all, occupations. Upon further reconsideration, we have therefore elected to retain the minimum 30 percent evaluation for loss of a single kidney under diagnostic code 7500. One commenter felt that the proposed criteria for rating voiding dysfunction under Sec. 4.115a would be inadequate for evaluating veterans with neurogenic bladders who use either indwelling or intermittent catheterization to void, and suggested a separate diagnostic code for neurogenic bladder. Although a need for separate rating criteria was implied, the commenter offered no alternative criteria for our consideration. VA agrees that it would be useful to have a separate diagnostic code for this disability, which is common in cases of severe spinal cord injury. We have therefore added diagnostic code 7542 for neurogenic bladder with instructions to rate the condition under the criteria for voiding dysfunction, which we believe are adequate to evaluate neurogenic bladder. Neurogenic bladder is manifested as urine leakage or frequent urination, both of which correspond to categories of voiding dysfunction as proposed. In addition, the word ``appliance'' as used in the criteria for incontinence clearly includes all types of catheters as well as any other assistive device for urination. Under the general rating criteria for urinary frequency in Sec. 4.115a, we had proposed separate sets of evaluation criteria for daytime and nighttime frequency. The criteria for daytime frequency were assigned evaluations of 40, 20, and 10 percent. For nighttime frequency, awakening to void five or more times per night was proposed as 20 percent, awakening to void three to four times was assigned 10 percent, and one to two times was non-compensable. One commenter felt that the evaluations for nighttime frequency should be higher than proposed, while another believed that the distinction between daytime and nighttime frequency is artificial and should be eliminated. Separate criteria for nighttime frequency were proposed since a patient may be more likely to report this symptom to an examining physician, especially in the early stages of renal disease. Upon further review, however, VA agrees that nighttime frequency is just as indicative of significant disease as daytime frequency, and that different evaluation levels are not warranted. We have therefore incorporated the three levels originally proposed for nighttime frequency with the 40, 20, and 10 percent levels under daytime frequency. Instances in which a person is awakened to void only once a night, however, have not been made compensable, since this degree of frequency does not, in our judgment, impose a disability significant enough to warrant the payment of compensation. One commenter felt that the frequency of the need to change absorbent materials under the criteria for rating voiding dysfunction is not a useful measure of incontinence because: (1) The changing of absorbent materials does not accurately quantify the degree of disability, (2) the wearing of absorbent materials may be inappropriate for paraplegics, and (3) there is no objective method to determine the frequency of the need to change absorbent materials. We do not concur. A person who needs to change absorbent materials often has a greater loss of voluntary control than one who needs changes less frequently. The frequency of changes can be objectively reported either by the veteran or the person providing care, with the frequency of the need for such changes determined by an examining physician. These criteria represent, in our judgment, a satisfactory means to measure urinary incontinence and, since no reasonable alternative has been suggested, we have elected to retain them. For some persons, wearing absorbent materials may be inappropriate; such people require the use of a catheter or some other means to compensate for the loss of control. As previously discussed, the criteria at the 60 percent level addressing the use of such an appliance are adequate to evaluate the disabilities of those for whom the use of absorbent materials is inappropriate. One commenter remarked that the words ``increased to the next higher'' were unclear in the instruction for arteriolar nephrosclerosis following diagnostic code 7507. We agree that this language, which was retained from the prior rating schedule, is ambiguous. The intended effect is to recognize that heart disease or hypertension is more serious when the claimant also has renal disabilities. We have amended the instruction following diagnostic code 7507 to clarify this principle. Under the diagnostic codes for nephrolithiasis (7508), ureterolithiasis (7510), and stricture of the ureter (7511), a 30 percent evaluation was proposed for recurrent stone formation requiring diet therapy, drug therapy, or frequent surgical therapy. One commenter believed a higher evaluation should be assigned for ``frequent surgical therapy,'' since frequent surgery implies a condition more severe than one controlled through diet or drug therapy. By ``surgical therapy'' we meant to include extraction through a catheter or fragmentation through such means as extracorporeal shock wave lithotripsy. To remove any ambiguity and thus avoid confusion, we have amended the criteria under diagnostic codes 7508, 7510, and 7511 to refer to ``invasive or non- invasive procedures'' rather than ``surgical therapy,'' and we have replaced the term ``frequent'' with the more objective measurement of more than twice per year. One commenter stated that the words ``multiple urethroperineal'' in the evaluation criteria for fistula of the urethra (7519) were unclear. Once again, we agree that a term retained from the prior rating schedule is vague and potentially confusing. We have added the word ``fistulae'' to indicate that when there are two or more fistulous tracts draining from the perineum a 100 percent evaluation will be assigned. Under diagnostic code 7531 (kidney transplants), we originally proposed that a follow-up examination be conducted six months after surgery in the same manner as for malignancies (diagnostic code 7528). Diagnostic code 7531 previously required assignment of a 100 percent evaluation with a prospective reduction two years after surgery. Three commenters stated that a period longer than six months is warranted because of the fragile condition of these patients, the complications of surgery, the side-effects of immunosuppressive therapy, and the risk of transplant rejection. One commenter suggested that a one year period would be reasonable. Considering the possibility of late immunologic, medical, and surgical complications, we believe it is more reasonable to assess residual disability one year after surgery instead of six months. We have therefore amended the NOTE following diagnostic code 7531 to state that a mandatory VA examination will be conducted one year after hospital discharge instead of the six months originally proposed. A minimum rating of 30 percent was proposed under the diagnostic code for kidney transplant for as long as a patient is on immunosuppressive medication. One commenter stated that almost all persons who have undergone transplant surgery permanently require immunosuppressive medication. Upon further review, VA agrees that it is so seldom that immunosuppressive therapy can be stopped after transplantation, that the proposed exception to the minimum evaluation under diagnostic code 7531 is not necessary. We have deleted that exception from the final rule. One commenter believed that there should be an evaluation level of 30 percent in addition to the 20 percent level proposed under diagnostic code 7532, Renal tubular dysfunctions, since various renal tubular nephropathies may have severe disabling effects. Another commenter suggested that the category of renal tubular dysfunctions was too vague and seemed to embrace a variety of conditions which should be singly listed, and that they often render veterans unemployable due to the combination of treatment and symptoms. Renal tubular disorders include disorders of the proximal nephron function, disorders of function of the ascending limb of the loop of Henle, and disorders of distal nephron function. We have amended the parenthetical portion of the heading of diagnostic code 7532 to include additional examples of these diseases, which have common characteristics and should therefore be rated under the same criteria to ensure consistency. These conditions generally cause metabolic imbalances which can be adequately treated by replacement therapy; as such, in our judgment, they do not warrant an evaluation greater than 20 percent. They may on occasion, however, result in more severe kidney dysfunction. For that reason we have added an instruction to alternatively rate this disability as renal dysfunction, which will allow evaluations greater than 20 percent. One commenter stated that in keeping with ``current BVA [Board of Veterans Appeals] policy,'' the diagnostic code for penile deformity with loss of erectile power (7522) should provide a 20 percent evaluation even when erectile power has been restored by means of a penile implant. VA does not concur. Under diagnostic code 7522, two distinct elements are required for a 20 percent evaluation: (1) Penile deformity and (2) loss of erectile power. If either element is absent following insertion of a penile implant or for any other reason the criteria for a 20 percent evaluation under this code are not met, and the instruction which the commenter requests is therefore not warranted. VA regulations are binding upon all agencies within the Department of Veterans Affairs, and neither BVA nor any other VA agency is free to adopt an official policy which is contrary to established regulations. The same commenter also requested that we add a NOTE to diagnostic code 7522 indicating entitlement to special monthly compensation under 38 U.S.C. 1114(k). Although loss of erectile power establishes entitlement to special monthly compensation under 38 U.S.C. 1114(k), we do not believe that a NOTE to such effect in the rating schedule is warranted. The criteria regarding entitlement to special monthly compensation are extensive, very complicated, and seldom correspond exactly to evaluation criteria in the rating schedule. For that reason, it is important that raters refer to the regulations governing special monthly compensation rather than relying on cross-references in the rating schedule. One commenter objected to the proposed elimination of a compensable evaluation for loss of a single testicle under diagnostic code 7524, alleging that such loss disrupts normal endocrine function and interferes with the maintenance of secondary sex characteristics. VA does not concur. In fact, any retrogressive changes in secondary sex characteristics even following removal of both testes after sexual maturity would occur slowly, if at all (Oswald S. Lowsley and T.J. Kirwin, ``Clinical Urology'' 230 (Williams and Wilkins 1956)). A solitary testis is in most cases adequate to sustain normal endocrine function without hormone replacement therapy. No significant employment handicap would likely result from this condition and a compensable evaluation, in our judgment, is not warranted. The same commenter objected to the proposed elimination of the minimum rating of 20 percent for removal of the prostate gland (diagnostic code 7526). VA does not concur. Because of the development of improved surgical techniques for extraction of the prostate through the perineum, bladder, surrounding capsule, or urethra, a minimum disability evaluation of 20 percent is not warranted. Often the only residual of this surgery is sterility, which is compensated not under the rating schedule but by means of special monthly compensation under 38 U.S.C. 1114(k). Should any other disability result, it would be rated under the diagnostic code for injuries, infections, hypertrophy, and postoperative residuals of the prostate gland (7527), with evaluations based on the criteria for voiding dysfunction or urinary tract infections. In our judgment, this provision allows for a broad enough range of evaluations to rate residual disability as established by medical examination. Three commenters urged that the previous convalescent period of one year following cancer treatment (diagnostic code 7528) be retained, stating that the complexity of certain medical procedures, the wide variety of possible side-effects, and the time required to recover from treatment precludes any realistic reduction of these recuperative periods. The commenters appear to have misinterpreted the proposed rule to mean that a convalescent evaluation will terminate after six months. The rule actually requires an examination, not a reduction, six months after the assignment of total benefits. If the claimant remains totally disabled, the 100 percent evaluation will continue without interruption. If a reduction in evaluation is warranted, it will be implemented under the provisions of 38 CFR 3.105(e). This application of total convalescence evaluations will take into account the wide array of possible side-effects and complications of treatment by ensuring that any changes in evaluation are supported by the specific findings of a current medical examination. A total evaluation will extend indefinitely after treatment is discontinued, with a required VA examination six months thereafter. If the results of this or any subsequent examination warrant a reduction in evaluation, the reduction will be implemented under the provisions of 38 CFR 3.105(e). There can be no reduction at the end of six months since any proposed reduction would be based on the examination and the notification process can begin only after the examination is reviewed. This method also has the advantage of offering the veteran more contemporary notice of any proposed action and, under the provisions of 38 CFR 3.105(e), expanding the opportunity to present evidence showing that the proposed action should not be taken. We have revised the wording of the NOTE based upon the concerns of the commenters, however, to ensure that it cannot be misinterpreted as requiring a reduction six months after treatment is terminated. Several commenters objected to the elimination of a minimum 10 percent evaluation following treatment of cancer under diagnostic code 7528. One commenter stated that malignancies of this kind result in a ``permanent mental fixation.'' Another commenter stated that there may be residual damage to the genitourinary system from radiation treatment. VA acknowledges that disability often follows cancer treatment, and residual impairment of the genitourinary system will accordingly be rated as either voiding or renal dysfunction. Although any residual warranting compensation would be ascertainable on VA examination, the existence of such residuals cannot be presumed in every case. Psychiatric or any other complications are subject to service connection under 38 CFR 3.310(a) of this chapter. The recurrence of cancer at any time would warrant restoration of the 100 percent evaluation. Rating the actual residuals will in our judgment allow assignment of an evaluation reflecting the true severity of the individual disability. One commenter stated that because the proposed amendments included reductions in certain percentage evaluations, VA was exceeding the GAO mandate to review the rating schedule for the purpose of updating medical terminology and evaluation criteria. VA does not concur. VA's mandate to review the rating schedule derives from the statutory authority which Congress has granted the Secretary of Veterans Affairs to adopt a schedule of ratings, including the authority to establish percentage evaluations (38 U.S.C. 1155). Although GAO may recommend that the Secretary review the schedule from a particular perspective, it has no authority to limit the scope of any review which the Secretary subsequently conducts under that statutory authority. The GAO recommendations resulted from a study finding that the rating schedule uses outdated medical terminology, contains ambiguous rating criteria, and does not reflect recent medical advances. If it is to conduct a good faith review, particularly when considering medical advances, VA cannot preclude the possibility that some evaluations may be changed. Congress, in fact, specifically foresaw such a possibility when it enacted legislation to amend 38 U.S.C. 1155 in order to protect the level of evaluations assigned under superseded rating criteria. (See 137 Cong. Rec. H5928 (daily ed. July 29, 1991) (statement of Rep. Montgomery).) One commenter implied that the proposed changes could not be made without statistical studies showing the economic impact of genitourinary impairments on disabled individuals. He cited a statistical study conducted in the 1960s which he contends does not support the proposed reductions. The statute authorizing establishment of the schedule directs that ``[t]he Secretary shall from time to time readjust the schedule of ratings in accordance with experience'' (emphasis supplied). Rather than requiring statistical studies or any other specific type of data, the statute clearly leaves the nature of the experience which warrants an adjustment, and by extension the manner in which any review is conducted, to the discretion of the Secretary. Although during the 1970s VA considered adjusting the rating schedule based on the same statistical studies cited by the commenter, that approach proved to be unsatisfactory and the proposed changes were not adopted. To allow as much public participation in the process as possible, we published an Advance Notice of Proposed Rulemaking (ANPRM) in the Federal Register on August 21, 1989 (54 FR 34531-2). We received responses from VA employees, the Naval Physical Evaluation Board, the Veterans of Foreign Wars, the Disabled American Veterans, the Director of Urology Programs at the National Institutes of Health, and the general public. We also contracted with an outside consultant to suggest revisions. In formulating recommendations, the consultant convened a five-member panel of physicians, each specializing in a different aspect of urology. We developed our proposed changes only after reviewing all of the material received in response to the ANPRM, from the consultant, and from specialists from the Veterans Health Administration in renal diseases. One commenter believed that the proposed changes did not reflect the average person's ability to cope with genitourinary disorders as 38 U.S.C. 1155 requires, but were instead based upon optimum success in overcoming the effects of disease and the results of surgery. Presumably the commenter was referring to the convalescent periods specified under various diagnostic codes in this portion of the schedule. VA does not concur. 38 U.S.C. 1155 directs that ``ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations.'' The word ``average,'' as used in the statute, refers to the ``usual or normal kind, amount, quality, rate, etc.'' (``Webster's New World Dictionary,'' Third College Edition). We have outlined above the range of medical advice available to us when we conducted this review. The convalescent periods adopted in this change represent in our judgment, based on sound medical advice, neither the longest nor shortest periods that any individual patient might require for recovery, but the usual or normal periods during which a normal patient, under normal circumstances, would be expected to recover from a specific condition or surgical procedure. We also note that these convalescent periods represent the point at which the individual patient's condition is to be evaluated by examination, and do not preclude an extension of a total evaluation if appropriate based on the individual patient's condition. (See comments regarding diagnostic code 7528.) Another commenter believed that certain changes were proposed ``with an eye towards cost cutting.'' As discussed above, the revisions were proposed based on medical considerations; no cost studies or projections were conducted in conjunction with this review. Cost cutting therefore was not an issue, and we believe that these revisions will prove to have negligible budget impact. One commenter stated that VA should consider the effects of genitourinary conditions on life expectancy when revising this portion of the rating schedule. VA does not concur. To consider a factor so far removed from ``the average impairments of earning capacity'' as the effects of various conditions on life expectancy would clearly exceed the parameters established by Congress in 38 U.S.C. 1155. One commenter contended that it would be unfair for VA to reduce any of the evaluations in the current rating schedule because doing so could prevent some veterans from maintaining their current levels of evaluation and thereby deprive them of the protection which would otherwise attach to those evaluation levels after 20 years under the provisions of 38 U.S.C. 110. VA does not concur. In section 103(a) of the Veterans' Benefits Programs Improvement Act of 1991 (Pub. L. 102-86), Congress modified 38 U.S.C. 1155 to provide that a readjustment to the rating schedule will not result in a reduction of any disability evaluation in effect on the date of the readjustment unless that disability has actually improved. The statute effectively protects against the situation which the commenter anticipates. Since no evaluation may be reduced solely due to a readjustment to the rating schedule, a readjustment cannot compromise the potential for any veteran to have an evaluation preserved under the provisions of 38 U.S.C. 110. One commenter suggested that VA allow special monthly compensation at the level for aid and attendance whenever a veteran requires hemodialysis three or more times a week. Another commenter suggested that we allow special monthly compensation under 38 U.S.C. 1114 (k) for loss of a single kidney. VA does not concur. The entitlement criteria for special monthly compensation are established by Congress and codified at 38 U.S.C. 1114 (k) through (s). Regulations implementing these statutory grants of special monthly compensation are found in VA's Adjudication regulations (38 CFR part 3) rather than in the Schedule for Rating Disabilities (38 CFR part 4). This issue is therefore beyond the scope of the current rulemaking. VA appreciates the comments submitted in response to the proposed rule, which is now adopted with the amendments noted above. The Secretary hereby certifies that this regulatory amendment will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. The reason for this certification is that this amendment would not directly affect any small entities. Only VA beneficiaries could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this amendment is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604. In accordance with Executive Order 12291, Federal Regulation, the Secretary has determined that this regulatory amendment is non-major for the following reasons: (1) It will not have an annual impact on the economy of $100 million or more. (2) It will not cause a major increase in costs or prices. (3) It will not have significant adverse effects on competition, employment, investment, productivity, innovation, or on the ability of United States-based enterprises to compete with foreign-based enterprises in domestic or export markets. The Catalog of Federal Domestic Assistance numbers are 64.104 and 64.109. List of Subjects in 38 CFR Part 4 Handicapped, Pensions, Veterans. Approved: March 5, 1993. Jesse Brown, Secretary of Veterans Affairs. Editorial note: This document was received at the Office of the Federal Register on January 11, 1994. For the reasons set out in the preamble, 38 CFR part 4, subpart B, is amended as set forth below: PART 4--SCHEDULE FOR RATING DISABILITIES Subpart B--Disability Ratings 1. The authority citation for part 4 continues to read as follows: Authority: 72 Stat. 1125; 38 U.S.C. 1155. 2. Section 4.115 is amended by adding two sentences at the end of the section to read as follows: Sec. 4.115 Nephritis. * * * If, however, absence of a kidney is the sole renal disability, even if removal was required because of nephritis, the absent kidney and any hypertension or heart disease will be separately rated. Also, in the event that chronic renal disease has progressed to the point where regular dialysis is required, any coexisting hypertension or heart disease will be separately rated. 3. Section 4.115a is redesignated and revised as Sec. 4.115b and a new Sec. 4.115a is added to read as follows: Sec. 4.115a Ratings of the genitourinary system--dysfunctions. Diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. The following section provides descriptions of various levels of disability in each of these symptom areas. Where diagnostic codes refer the decisionmaker to these specific areas dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. Since the areas of dysfunction described below do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis. ------------------------------------------------------------------------ Rating ------------------------------------------------------------------------ Renal dysfunction: Requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, estpecially cardiovascular.................... 100 Persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion.................................... 80 Constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101......................... 60 Albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101.................................................... 30 Albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101...... 0 Voiding dysfunction: Rate particular condition as urine leakage, frequency, or obstructed voiding Continual Urine Leakage, Post Surgical Urinary Diversion, Urinary Incontinence, or Stress Incontinence: Requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day.... 60 Requiring the wearing of absorbent materials which must be changed 2 to 4 times per day................................. 40 Requiring the wearing of absorbent materials which must be changed less than 2 times per day............................ 20 Urinary frequency: Daytime voiding interval less than one hour, or; awakening to void five or more times per night............................ 40 Daytime voiding interval between one and two hours, or; awakening to void three to four times per night.............. 20 Daytime voiding interval between two and three hours, or; awakening to void two times per night........................ 10 Obstructed voiding: Urinary retention requiring intermittent or continuous characterization............................................. 30 Marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: 1. Post void residuals greater than 150 cc. 2. Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec). 3. Recurrent urinary tract infections secondary to obstruction. 4. Stricture disease requiring periodic dilatation every 2 to 3 months................................................ 10 Obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year................... 0 Urninary tract infection: Poor renal function: Rate as renal dysfunction. Recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management.................... 30 Long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management.................. 10 ------------------------------------------------------------------------ Sec. 4.115b Ratings of the genitourinary system--diagnoses. ------------------------------------------------------------------------ Rating ------------------------------------------------------------------------ 7500Kidney, removal of one: Minimum evaluation........................................ 30 Or rate as renal dysfunction if there is nephritis, infection, or pathology of the other. 7501Kidney, abscess of: Rate as urinary tract infection........................... 30 7502Nephritis, chronic: Rate as renal dysfunction. 7504Pyelonephritis, chronic: Rate as renal dysfunction or urinary tract infection, whichever is predominant. 7505Kidney, tuberculosis of: Rate in accordance with Secs. 4.88b or 4.89, whichever is appropriate. 7507Nephrosclerosis, arteriolar: Rate according to predominant symptoms as renal dysfunction, hypertension or heart disease. If rated under the cardiovascular schedule, however, the percentage rating which would otherwise be assigned will be elevated to the next higher evaluation. 7508Nephrolithiasis: Rate as hydronephrosis, except for recurrent stone formation requiring one or more of the following: 1. diet therapy 2. drug therapy 3. invasive or non-invasive procedures more than two times/year............................................. 30 7509Hydronephrosis: Severe; Rate as renal dysfunction. Frequent attacks of colic with infection (pyonephrosis), kidney function impaired................................... 30 Frequent attacks of colic, requiring catheter drainage...... 20 Only an occasional attack of colic, not infected and not requiring catheter drainage................................ 10 7510Ureterolithiasis: Rate as hydronephrosis, except for recurrent stone formation requiring one or more of the following: 1. diet therapy 2. drug therapy 3. invasive or non-invasive procedures more than two times/year............................................. 30 7511Ureter, stricture of: Rate as hydronephrosis, except for recurrent stone formation requiring one or more of the following: 1. diet therapy 2. drug therapy 3. invasive or non-invasive procedures more than two times/year............................................. 30 7512Cystitis, chronic, includes interstitial and all etiologies, infectious and non-infectious: Rate as voiding dysfunction. 7515Bladder, calculus in, with symptoms interfering with function: Rate as voiding dysfunction 7516Bladder, fistula of: Rate as voiding dysfunction or urinary tract infection, whichever is predominant. Postoperative, superapubic cystotomy...................... 100 7517Bladder, injury of: Rate as voiding dysfunction. 7518Urethra, stricture of: Rate as voiding dysfunction. 7519Urethra, fistual of: Rate as voiding dysfunction. Multiple urethroperineal fistulae......................... 100 7520Penis, removal of half or more.............................. 30 Or rate as voiding dysfunction. 7521Penis removal of glans...................................... 20 Or rate as voiding dysfunction. 7522Penis, deformity, with loss of erectile power............... 20 7523Testis, atrophy complete: Both...................................................... 20 One....................................................... 0 7524Testis, removal: Both...................................................... 30 One....................................................... 0 Note--In cases of the removal of one testis as the result of a service-incurred injury or disease, other than an descended or congenitally undeveloped testis, with the absence or nonfunctioning of the other testis unrelated to service, an evaluation of 30 percent will be assigned for the service-connected testicular loss. Testis, undescended, or congenitally undeveloped is not a ratable disability. 7525Epididymo-orchitis, chronic only: Rate as urinary tract infection. For tubercular infections: Rate in accordance with Secs. 4.88b or 4.89, whichever is appropriate. 7527Prostate gland injuries, infections, hypertrophy, postoperative residuals: Rate as voiding dysfunction or urinary tract infection, whichever is predominant. 7528Malignant neoplasms of the genitourinary system............. 100 Note--Following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of Sec. 3.105(e) of this chapter. If there has been no local reoccurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 7529Benign neoplasms of the genitourinary system: Rate as voiding dysfunction or renal dysfunction, whichever is predominant. 7530Chronic renal disease requiring regular dialysis: Rate as renal dysfunction. 7531Kidney transplant: Following transplant surgery.............................. 100 Thereafter: Rate on residuals as renal dysfunction, minimum rating........................................... 30 Note--The 100 percent evaluation 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 based upon that or any subsequent examination shall be subject to the provisions of Sec. 3.105(e) of this chapter. 7532Renal tubular disorders (such as renal glycosurias, aminoacidurias, renal tubular acidosis, Fanconi's syndrome, Bartter's syndrome, related disorders of Henle's loop and proximal or distal nephron function, etc.): Minimum rating for symptomatic condition.................. 20 Or rate as renal dysfunction. 7533Cystic diseases of the kidneys (polycystic disease, uremic medullary cystic disease, Medullary sponge kidney, and similar conditions): Rate as renal dysfunction. 7534Atherosclerotic renal disease (renal artery stenosis or atheroembolic renal disease): Rate as renal dysfunction. 7535Toxic nephropathy (antibotics, radiocontrast agents, nonsteroidal anti-inflammatory agents, heavy metals, and similar agents): Rate as renal dysfunction. 7536Glomerulonephritis: Rate as renal dysfunction. 7537Interstitial nephritis: Rate as renal dysfunction. 7538Papillary necrosis: Rate as renal dysfunction. 7539Renal amyloid disease: Rate as renal dysfunction. 7540Disseminated intravascular coagulation with renal cortical necrosis: Rate as renal dysfunction. 7541Renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes. Rate as renal dysfunction. 7542Neurogenic bladder: Rate as voiding dysfunction. ------------------------------------------------------------------------ [FR Doc. 94-1045 Filed 1-14-94; 8:45 am] BILLING CODE 8320-01-P