Vol. 76 Tuesday, No. 128 July 5, 2011

Part II

Department of Veteran Affairs

38 CFR Part 4 Schedule for Rating Disabilities; The Digestive System; Proposed Rule

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DEPARTMENT OF VETERANS medical conditions not currently in the The same commenter suggested that AFFAIRS rating schedule, and implement current we delete diagnostic codes 7201 (lips, medical criteria and terminology that injuries of), 7205 (, 38 CFR Part 4 reflect recent medical advances. diverticulum of, acquired), 7306 RIN 2900–AN12 Comments in Response To Advance (marginal ulcer), 7309 (, Notice of Proposed Rulemaking stenosis of), 7310 (stomach, injury of, Schedule for Rating Disabilities; The residuals), 7315 (chronic cholelithiasis), Digestive System In response to the advance notice of 7316 (chronic cholangitis), 7324 proposed rulemaking, we received (distomiasis, intestinal or hepatic), and AGENCY: Department of Veterans Affairs. comments from the American Legion 7342 () because they are ACTION: Proposed rule. and from several VA employees. One commenter suggested that we add to the rare. SUMMARY: The Department of Veterans rating schedule Crohn’s ; We propose to remove diagnostic Affairs (VA) proposes to amend the esophageal spasm (with its own code 7342 (visceroptosis) because portion of the Schedule for Rating evaluation criteria); A, B, and visceroptosis is an obsolete diagnosis, as Disabilities that addresses the Digestive C; chronic of the and discussed further below. However, we System. The purpose of this change is its residuals; and due to propose to retain all of the other to incorporate medical advances that . We propose to diagnostic codes mentioned by the have occurred since the last review, address each of these conditions in this commenter, although some in a revised insert current medical terminology, and revision, except for hepatitis and form, since some of them, such as provide clear criteria. chronic inflammation of the liver, diagnostic code 7315 (cholelithiasis), DATES: Comments must be received by which were addressed in a separate represent common digestive , VA on or before September 6, 2011. rulemaking on liver disabilities (66 FR and others, such as those for injuries of ADDRESSES: Written comments may be 29486, May 31, 2001). the lips or stomach, may be the only submitted through http:// The same commenter suggested we appropriate codes under which to include reflux with hiatal www.Regulations.gov; by mail or hand- address injuries, including combat , with the criteria taking into delivery to the Director, Regulations , to those parts of the body. account a measurement of reflux. For Management (02REG), Department of They may therefore be useful to VA for Veterans Affairs, 810 Vermont Ave., esophageal abnormalities, reflux measurement (manometry), barium statistical purposes, as well as for rating NW., Room 1068, Washington, DC purposes. 20420; or by fax to (202) 273–9026. swallows, and esophagoscopy provide Comments should indicate that they are information about physiological and Another commenter suggested we submitted in response to RIN 2900– anatomical abnormalities, and may be remove diagnostic code 7201 (lips, AN12–Schedule for Rating Disabilities; useful for diagnosis and prognosis, for injuries of); add esophagitis, , determining response to therapy, and to The Digestive System. Copies of and Crohn’s disease; provide a prepare for . They are less useful, comments received will be available for diagnostic code for total ; however, in assessing the level of public inspection in the Office of add a 10-percent evaluation level for disability than the severity of Regulation Policy and Management, ; provide evaluation criteria for symptoms, the impact of the condition Room 1063B, between the hours of and ; and provide on the nutritional status of the patient, 8 a.m. and 4:30 p.m. Monday through objective evaluation criteria for and the potential for remediation Friday (except holidays). Please call . We have already discussed (‘‘Disability Evaluation’’ 379 (Stephen L. (202) 461–4902 for an appointment. injuries of the lips, which we propose Demeter, M.D., Gunnar B.J. Anderson, (This is not a toll-free number.) In to retain. We otherwise propose to M.D., and George M. Smith, M.D., 1996) addition, during the comment period, follow all of these suggestions, with two and The Merck Manual 113 (18th ed. comments may be viewed online exceptions. First, we do not propose to 2006)). While we propose to address through the Federal Docket Management add a diagnostic code for total reflux esophagitis in this revision, as System at http://www.Regulations.gov. gastrectomy, because that condition can discussed further below, we do not FOR FURTHER INFORMATION CONTACT: be appropriately evaluated under an propose to use a measurement of reflux existing diagnostic code (7308, Thomas J. Kniffen, Chief, Regulations for evaluation. Postgastrectomy syndromes). Second, Staff (211D), Compensation and Pension A second commenter suggested we Service, Veterans Benefits add Crohn’s disease and also revise the we have already added a 10-percent Administration, Department of Veterans criteria for . We propose to evaluation level for cirrhosis in the Affairs, 810 Vermont Avenue, NW., do both. separate rulemaking that addressed Washington, DC 20420, (202) 461–9725. One commenter suggested that we disabilities of the liver (66 FR 29486, (This is not a toll-free number.) evaluate gastrectomy and vagotomy- May 31, 2001), so there is no need for SUPPLEMENTARY INFORMATION: VA pyloroplasty under the same criteria. further action in this proposed rule published an advance notice of The major postoperative problem based on that comment. This proposed rulemaking in the Federal related to gastrectomy is dumping commenter also suggested we remove Register of May 2, 1991 (56 FR 20168), syndrome, which is the common term diagnostic codes 7342 (visceroptosis) advising the public of our intent to that refers to the group of symptoms that and 7337 () and that we revise and update the portion of the may occur following various types of delete the word ‘‘infectious’’ from Schedule for Rating Disabilities (the surgery for ulcer disease. Many ‘‘infectious hepatitis.’’ We also propose rating schedule) that addresses the problems may be associated with to remove diagnostic codes 7342 and digestive system as well as to solicit and vagotomy-pyloroplasty, of which 7337. The suggested change concerning obtain comments and suggestions from is only one. We hepatitis was made in the separate interest groups and the general public. therefore propose to retain separate rulemaking for liver disabilities, so there By revising the rating schedule, we aim evaluation criteria for these conditions, is no need for further action in this to eliminate ambiguities, include as discussed in more detail below. proposed rule.

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Outside Consultants rumbling bowel sounds), crampy pain, We propose to direct the rater to In addition to publishing an advance and obstipation (severe ). separately evaluate two or more conditions in § 4.114 only if the signs notice of proposed rulemaking, VA Section 4.111 contracted with an outside consulting and symptoms attributed to each are firm for the purpose of gathering Current § 4.111, ‘‘Postgastrectomy separable, and if they are not separable, suggestions for changes in the rating syndromes,’’ discusses dumping to assign a single evaluation under the schedule to help fulfill the goals of syndrome, a condition which is relevant diagnostic code that best allows revising and updating the medical only to diagnostic code 7308, evaluation of the overall functional criteria. This proposed amendment ‘‘postgastrectomy syndromes,’’ and we impairment resulting from both includes many of their suggestions. propose to list the symptoms of conditions. With these instructions, the Since one of the goals of the rating dumping syndrome in a note under that list of conditions that may not be schedule revision is to eliminate diagnostic code. We therefore propose combined, given in current § 4.114, ambiguities, we did not follow some of to remove § 4.111. would be unnecessary, and we propose our consultants’ recommendations that Section 4.112 to remove it. This revision would are based, at least, in part, on subjective provide a fair and equitable method of or indefinite language when more Current § 4.112, ‘‘Weight loss,’’ evaluation, and is not contrary to § 4.14. objective terminology could be used. defines ‘‘substantial weight loss,’’ In addition, it would remove the Furthermore, each group of consultants ‘‘minor weight loss,’’ ‘‘inability to gain somewhat unclear direction to assign a reviewed only one portion or body weight,’’ and ‘‘baseline weight,’’ for diagnostic code that reflects the system of the rating schedule, and we purposes of evaluating conditions in predominant disability and elevate to had to assess the feasibility of their § 4.114. Some of the revisions of the next higher evaluation level ‘‘where recommendations in light of the entire conditions in § 4.114 that we are the severity of the overall disability rating schedule, in order to assure proposing have evaluation criteria that warrants such elevation,’’ a direction internal consistency. Relevant are based in part on , and that could be interpreted differently by recommendations from our consultants there is no universally accepted different individuals. We also propose are discussed below. definition of malnutrition. We, to change the title of § 4.113 to therefore, propose to provide a ‘‘Evaluation of coexisting digestive Section 4.110 definition of malnutrition for purposes conditions,’’ since not all disabilities in Current § 4.110, ‘‘Ulcers,’’ explains of evaluating conditions in § 4.114 by this body system are abdominal, as the that ‘‘the term ‘peptic ulcer’ is not expanding the title of § 4.112 to ‘‘Weight current title of § 4.113 implies. sufficiently specific for rating purposes’’ loss and malnutrition’’ and adding the because there are ‘‘manifest differences’’ following definition: ‘‘ ‘malnutrition’ Section 4.114 Schedule of Ratings- between ulcers of the stomach or means a deficiency state resulting from Digestive System as compared to those at an insufficient intake of one or multiple Mouth injuries, Lip injuries, Tongue anastomotic stoma, and that, therefore, essential nutrients or the inability of the Injuries (Including Tongue Loss), the location of an ulcer should be body to absorb, utilize, or retain such , Achalasia identified in order to evaluate it. This nutrients. It is characterized by failure (Cardiospasm) and Other Motor material is unnecessary, since there are of the body to maintain normal Disorders of the Esophagus, and separate diagnostic codes for ulcers of functions and healthy tissues.’’ Esophageal Diverticula (Diagnostic the stomach, duodenum, and Section 4.113 Codes 7200–7205) gastrojejunal area (or anastomotic stoma), and the rating schedule Current § 4.113, ‘‘Coexisting The current rating schedule directs therefore makes it clear that the site of abdominal conditions,’’ states that there that injuries of the mouth (diagnostic an ulcer must be identified in order to are diseases of the digestive system that code 7200) be evaluated on the basis of assign the correct diagnostic code. produce a common disability picture disfigurement and impairment of Furthermore, this section establishes no with similar symptoms and which masticatory function, and injuries of the procedures that raters must follow in should therefore not be rated separately, lips (diagnostic code 7201) on the basis evaluating ulcer disease. We therefore as this would be a violation of 38 CFR of disfigurement of the face. Both mouth propose to remove the material 4.14, ‘‘Avoidance of pyramiding’’ and lip injuries are therefore evaluated currently in § 4.110, retitle this section (which states that the evaluation of the using criteria under other diagnostic ‘‘Dyspepsia,’’ and provide in it a same disability under various diagnoses codes. Loss of whole or part of the definition of the term ‘‘dyspepsia’’ for is to be avoided). Current § 4.114, in an tongue (diagnostic code 7202) is purposes of evaluating conditions in introductory paragraph, lists specific currently evaluated at 100 percent if § 4.114. We propose that § 4.110 would diagnostic codes that cannot be there is inability to communicate by define dyspepsia as any combination of combined, and directs that a single speech, at 60 percent if there is loss of the following symptoms: Gnawing or evaluation ‘‘be assigned under the one-half or more of the tongue, and at burning epigastric or substernal pain diagnostic code that reflects the 30 percent if there is marked speech that may be relieved by food (especially predominant disability picture, with impairment. Findings in these three milk) or antacids, , vomiting, elevation to the next higher evaluation conditions sometimes overlap, (lack or loss of appetite), where the severity of the overall according to our consultants, with the abdominal bloating, and belching. It disability warrants such evaluation.’’ In major problems being (1) Difficulty with would also state that when there is order to provide clear guidance about mastication (chewing) or swallowing, obstruction of the outlet of the stomach evaluation when there are two or more causing a restriction of diet; (2) (gastric outlet obstruction), dyspepsia coexisting digestive conditions, we difficulty with speech; (3) loss of part of may also include symptoms of propose to revise the material in the tongue; and (4) disfigurement. We gastroesophageal reflux (flow of §§ 4.113 and 4.114 related to this subject therefore propose to provide a general stomach contents back into the and place the revised directions in rating formula for the evaluation of esophagus), borborygmi (audible § 4.113. residuals of mouth injuries, lip injuries,

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and tongue injuries, including tongue our judgment, it is feasible and or pulmonary ) due to loss. preferable to provide a single diagnostic regurgitation or vomiting; or inability to In addition, there are several code with a broad range of evaluations speak clearly enough to be understood. esophageal abnormalities with signs and (100 to 10 percent), for the sake of We propose a 60-percent evaluation for symptoms that are similar to one promoting more consistent and any of the following: Diet restricted to another, and that also overlap the appropriate evaluations. liquid and soft solid foods, with findings in mouth, lip, and tongue Acquired diverticulum of the substantial weight loss or anemia; two injuries. For these reasons, we propose esophagus (diagnostic code 7205) is to three episodes per year of pulmonary to include several esophageal conditions currently evaluated as obstruction aspiration (with bronchitis, pneumonia, in the same general rating formula for (stricture). We propose to revise the title or pulmonary abscess) due to this whole group of conditions, as of diagnostic code 7205 from regurgitation or vomiting; or inability to discussed in more detail below. Our ‘‘Esophagus, diverticulum of’’ to speak clearly enough to be understood consultants recommended that there be ‘‘Esophageal diverticula, including at least half of the time but not all of the a 10-percent evaluation level for each of pharyngoesophageal (Zenker’s), time. We propose a 30-percent these disabilities, and also pointed out midesophageal, and epiphrenic types’’ evaluation for any of the following: Diet that stricture of the esophagus, for to indicate more clearly the several restricted to liquid and soft solid foods, example, can be totally disabling. We types of diverticula that may warrant with minor weight loss; esophageal agree, and propose to provide evaluation under this diagnostic code. dilation carried out five or more times evaluation levels of 100, 60, 30, and 10 Achalasia and esophageal diverticulum per year; daily regurgitation or vomiting; percent in this general rating formula. result in impairments similar to one one episode per year of pulmonary Stricture of the esophagus (diagnostic another, and there is overlap with aspiration (with bronchitis, pneumonia, code 7203) is currently evaluated at 80 impairments resulting from mouth, lip, or pulmonary abscess) due to percent if it permits ‘‘passage of liquids and tongue injuries. In addition, regurgitation or vomiting; or inability to only, with marked impairment of esophageal stricture, achalasia, and speak clearly enough to be understood general health;’’ at 50 percent if it is esophageal diverticulum may all result at times, but less than half of the time. ‘‘severe, permitting liquids only;’’ and at in pulmonary aspiration (inhaling food We propose a 10-percent evaluation for 30 percent if it is ‘‘moderate.’’ These or liquid into the lungs) due to any of the following: Diet restricted to criteria contain subjective terms such as regurgitation or vomiting and may liquid and soft solid foods; esophageal ‘‘marked,’’ ‘‘moderate,’’ and ‘‘severe,’’ require treatment with prescription dilation carried out one to four times which could be interpreted differently medication to control symptoms. per year; (pyrosis) requiring by different individuals. The general Esophageal dilation may be required for continous treatment with prescription rating formula we are proposing for the stricture or achalasia. We therefore and at least one of the following other evaluation of this and other related propose to include criteria for these symptoms: Retrosternal chest pain, conditions with symptoms in common esophageal conditions, as well as difficulty swallowing (dysphagia), or would provide more objective criteria. mouth, lip, and tongue injuries, in a pain during swallowing (odynophagia); Spasm of the esophagus general rating formula that encompasses partial tongue loss; or impaired (cardiospasm) (diagnostic code 7204) is the main signs and symptoms of all. articulation for some words, but speech currently evaluated based on the degree We propose to title the general rating understandable. of obstruction (stricture), if not formula for this group of conditions as We also propose to add a note amenable to dilation. We propose to follows: ‘‘General Rating Formula for directing raters to separately evaluate update the title of diagnostic code 7204 Residuals of mouth injuries (diagnostic mouth and lip injuries under diagnostic from ‘‘cardiospasm’’ to ‘‘achalasia,’’ the code 7200), Residuals of lip injuries code 7800 (Burn (s) of the head, current term for this condition. (diagnostic code 7201), Residuals of face, or neck; scar(s) of the head, face, Achalasia is a condition in which, upon tongue injuries, including tongue loss or neck due to other causes; or other swallowing, there is a failure of (diagnostic code 7202), Esophageal disfigurement of the head, face, or relaxation of the lower esophageal stricture (diagnostic code 7203), neck), if applicable, and to combine this sphincter (at the junction of the Achalasia (cardiospasm) and other with an evaluation under this general esophagus and stomach). We also motor disorders of the esophagus rating formula, under the provisions of propose to include in this diagnostic (diagnostic code 7204), and Esophageal § 4.25. code other related motor disorders of diverticula (diagnostic code 7205).’’ We The proposed general rating formula the esophagus with impairment in the propose to base evaluation of these for these conditions is broad enough to normal passage of food through the conditions on the extent of limitation of encompass any degree of severity of the esophagus due to muscle or nerve diet, on the extent of the ability to speak major types of impairment from any of abnormalities, by revising the title to clearly enough to be understood, on the these conditions, and from combined ‘‘Achalasia (cardiospasm) and other frequency of episodes of pulmonary injuries of more than one of these motor disorders of the esophagus aspiration due to regurgitation or structures. It also provides more (, corkscrew vomiting, and on whether or not objective criteria than the current esophagus, , etc.).’’ continuous treatment with prescription schedule because it excludes subjective Our consultants suggested we provide medication is required. We propose to descriptors like ‘‘marked’’ and more one diagnostic code for achalasia, with provide a list of findings at each sharply defines the extent of speech 100- and 30-percent evaluation levels, evaluation level, any of which would impairment and dietary limitations and another for other esophageal motor warrant that percentage of evaluation. required for various evaluations. disorders, with 50-, 30-, and 10-percent We propose a 100-percent evaluation Evaluations should, therefore, be more evaluation levels. However, the signs for any of the following: Tube feeding consistent. Although our consultants and symptoms of these conditions are required; diet restricted to liquid foods, used subjective terms such as very similar, and the severity of with substantial weight loss, ‘‘moderate’’ and ‘‘severe’’ in their disability from any one of these malnutrition, and anemia; four or more recommended criteria, we are proposing conditions varies widely from episodes per year of pulmonary to exclude such terms whenever individual to individual. Therefore, in aspiration (with bronchitis, pneumonia, possible throughout the revision of the

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rating schedule, for the sake of evaluated. It is an autoimmune disorder evaluation for three to five episodes per promoting consistent evaluations. Our that causes xerostomia (dry mouth) and year of partial obstruction of the bowel, consultants also included the nebulous keratoconjunctivitis sicca (dry eyes) and with typical signs and symptoms; and a phrase ‘‘interfering with normal daily may affect other parts of the body. The 10-percent evaluation for either of the functioning,’’ which could be subject to note directs that the effects of following: One or two episodes per year different interpretations by different xerostomia (dry mouth) due to Sjogren’s of partial obstruction of the bowel, with people, and we do not propose to use syndrome be evaluated under diagnostic typical signs and symptoms, or, in the this language. However, the criteria are code 7207, keratoconjunctivitis sicca absence of such episodes, pulling pain otherwise substantially the same as under the portion of the rating schedule on body movement, if not attributable to those our consultants recommended. that addresses Organs of Special Sense, another condition. and other effects of the syndrome, if These criteria are in general Salivary Gland Disease (Diagnostic any, on other body parts under agreement with those recommended by Code 7207) appropriate diagnostic codes in other our consultants, but they exclude Since there is no current diagnostic sections of the rating schedule. subjective terms such as ‘‘frequent,’’ code under which salivary gland disease ‘‘occasional,’’ and ‘‘severe’’ that the can be appropriately evaluated, and it is Peritoneal Adhesions (Diagnostic Code consultants suggested, in favor of more a common enough disability in veterans 7301) objective criteria in order to promote to require evaluation, we propose to add Peritoneal adhesions, diagnostic code consistent evaluations. diagnostic code 7207, ‘‘Salivary gland 7301, are currently evaluated at levels of A current note following diagnostic (parotid, submandibular, sublingual) 50, 30, 10, or zero percent. A 50-percent code 7301 states that ratings for disease other than .’’ We evaluation is assigned if adhesions are adhesions will be considered when propose that there be 20-, 10-, and zero- severe, with ‘‘definite partial there is a history of operative or other percent evaluation levels, based on the obstruction shown by X-ray, with traumatic or infectious (intraabdominal) presence of xerostomia (dry mouth) and frequent and prolonged episodes of process and at least two of the its effects, chronic inflammation or severe colic distention, nausea or following: Disturbance of motility, swelling of a salivary gland, salivary vomiting, following severe , actual partial obstruction, reflex gland calculi or stricture, increase in ruptured , perforated ulcer, or disturbances, or presence of pain. We dental caries, and weight loss, because operation with drainage.’’ A 30-percent propose to revise this note to state that these are the major impairments that evaluation is assigned if adhesions are evaluation under diagnostic code 7301 may result from salivary gland disease moderately severe, with ‘‘partial requires a history of abdominal or pelvic (‘‘Textbook of ’’ 225 obstruction manifested by delayed surgery, , irradiation, trauma, (Tadataka Yamada, M.D., ed., 1991)). motility of barium meal and less or other known etiology for peritoneal We propose a 20-percent evaluation frequent and less prolonged episodes of adhesions. We propose to add a second for xerostomia (dry mouth) with altered pain.’’ A 10-percent evaluation is note listing the typical signs and sensation of taste and difficulty with assigned if adhesions are moderate, with symptoms of partial , lubrication and mastication of food ‘‘pulling pain on attempting work or for purposes of evaluation under resulting in either weight loss or aggravated by movements of the body, diagnostic code 7301. This would increase in dental caries; a 10-percent or occasional episodes of colic pain, simplify the evaluation criteria by evaluation for xerostomia with altered nausea, constipation (perhaps eliminating the need to repeat the list of sensation of taste and difficulty with alternating with ) or abdominal symptoms at each level. Our consultants lubrication and mastication of food, but distention.’’ A zero-percent evaluation recommended that we provide a note without weight loss or increase in is assigned if adhesions are ‘‘mild.’’ similar to the current note, with both dental caries; chronic inflammation of a Subjective adjectives such as ‘‘mild,’’ causes and symptoms of adhesions salivary gland with pain and swelling ‘‘moderate,’’ ‘‘moderately severe,’’ and listed, and we have basically done this, on eating; one or more salivary calculi; ‘‘severe’’ are used at each level. but divided the material into two notes, or a salivary gland stricture. We propose We propose to provide evaluation for the sake of clarity. a zero-percent evaluation for either levels of 60, 30, or 10 percent for xerostomia without difficulty in peritoneal adhesions, based primarily General Rating Formula for Ulcer mastication of food, or painless swelling on the number of episodes of partial Disease (Diagnostic Codes 7304–7306) of the salivary gland. We are proposing intestinal obstruction with typical There are currently three diagnostic a zero-percent evaluation level in order symptoms, which may include, but are codes for ulcers: diagnostic code 7304 to make it clear that these findings not limited to colicky abdominal pain, for gastric ulcers, diagnostic code 7305 warrant a zero-, rather than a ten- abdominal distention, borborygmi for duodenal ulcers, and diagnostic code percent evaluation when it might (audible rumbling bowel sounds), 7306 for marginal (gastrojejunal) ulcers. otherwise be unclear to the rater. nausea, vomiting, and obstipation No specific evaluation criteria are We also propose to provide note (1) (severe constipation) (Yamada, 719). provided for gastric ulcers, but they are directing that facial nerve (cranial nerve X-ray confirmation of a partial bowel ordinarily rated under the criteria for VII) impairment, which may result from obstruction would be required for any duodenal ulcers. Duodenal ulcers are parotid gland disease or its treatment, be level of evaluation. currently evaluated at levels of 60, 40, evaluated under diagnostic code 8207 We propose a 60-percent evaluation 20, or 10 percent. A 60-percent (cranial nerve VII) and that any for six or more episodes per year of evaluation is assigned if the condition is disfigurement due to facial swelling be partial obstruction of the bowel severe, with pain only partially relieved evaluated under diagnostic code (Burn (confirmed by X-ray), with typical signs by ulcer therapy, and there is periodic scar(s) of the head, face, or neck; scar(s) and symptoms (which may include, but vomiting, recurrent or of the head, face, or neck due to other are not limited to colicky abdominal , with manifestations of anemia causes; or other disfigurement of the pain, abdominal distention, borborygmi and weight loss, productive of definite head, face, or neck). We propose to add (audible rumbling bowel sounds), impairment of health. A 40-percent note (2) to explain what Sjogren’s nausea, vomiting, and obstipation) evaluation is assigned if the condition is syndrome is and how it should be (severe constipation)); a 30-percent moderately severe, meaning that it is

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less than severe but with impairment of 7306), based on the recommended Chronic (Diagnostic Code health manifested by anemia and weight criteria. We also propose to change the 7307) loss, or that there are recurrent title of diagnostic code 7305 to We propose to revise the title of incapacitating episodes averaging 10 ‘‘duodenal ulcer or duodenitis’’ in order diagnostic code 7307 from the current days or more in duration at least four or to include duodenitis under this code, ‘‘gastritis, hypertrophic (identified by more times a year. A 20-percent because these conditions commonly gastroscope)’’ to ‘‘chronic gastritis evaluation is assigned if the condition is occur together and result in similar (including but not limited to erosive, moderate, with recurring episodes of findings. We propose to provide hypertrophic, hemorrhagic, bile reflux, severe symptoms two or three times a evaluation levels of 100, 60, 30, and 10 alcoholic, and drug-induced gastritis)’’ year averaging 10 days in duration, or percent. Our consultants suggested 60 to indicate that there are several types with continuous moderate percent as the highest level of of gastritis that may be evaluated under manifestations. A 10-percent evaluation evaluation, but, because our experience this code. is assigned if the condition is mild, with Gastritis is an inflammation of the recurring symptoms once or twice has shown that a number of veterans are gastric (stomach) mucosa. Common yearly. totally disabled by severe ulcer disease, causes include Helicobacter pylori Marginal ulcers are currently we propose to add a 100-percent level. evaluated under a separate set of criteria These levels also differ from the current infection, non-steroidal anti- that are similar to those for duodenal schedule by substituting a 30-percent inflammatory drugs, alcohol, stress, and ulcer, except that there is also a 100- level for the current 20- and 40-percent autoimmune phenomena (atrophic percent evaluation level, to be assigned levels. This change will provide a gastritis) (Merck, 117). While chronic if the condition is pronounced, with clearer distinction between the 10- gastritis is often asymptomatic (symptom-free), it may cause dyspepsia periodic or continuous pain unrelieved percent level and the next higher level and sometimes gastro-intestinal by standard ulcer therapy with periodic (which we propose to be 30 percent bleeding with resulting anemia. A rare vomiting, recurring melena or instead of 20 percent), a factor that will hematemesis, and weight loss, and the type of gastritis results in protein-losing promote more consistent evaluations, gastropathy (disease of the stomach), in condition is totally incapacitating. A 60- and will still be sufficient to percent evaluation is assigned if the which hypoalbuminia (low albumin accommodate the range of severity of level in blood), diarrhea, weight loss, condition is severe, with symptoms of ulcer disease. the same type as pronounced but less and edema may occur. Gastritis is pronounced and less continuous, with We propose a 100-percent evaluation currently evaluated at 60, 30, or 10 definite impairment of health. A 40- for either substantial weight loss, percent, with a 60-percent evaluation percent evaluation is assigned if the malnutrition, and anemia due to assigned when the condition is chronic, condition is moderately severe, with gastrointestinal bleeding; or for with severe hemorrhages or large intercurrent episodes of abdominal pain hospitalization three or more times per ulcerated or eroded areas; a 30-percent at least once a month partially or year for vomiting, refractory pain, evaluation when the condition is completely relieved by ulcer therapy, or gastrointestinal bleeding, perforation, chronic, ‘‘with multiple small eroded or there are mild and transient episodes of obstruction, or penetration to liver, ulcerated areas, and symptoms;’’ and a vomiting or melena. A 20-percent , or colon. We propose a 60- 10-percent evaluation when the evaluation is assigned if the condition is percent evaluation for either periodic or condition is chronic, ‘‘with small nodular lesions, and symptoms.’’ We moderate, with episodes of recurring constant dyspepsia with substantial propose to continue these evaluation symptoms several times a year. A 10- weight loss and anemia due to ulcer levels, but to provide different criteria, percent evaluation is assigned if the disease; or for hospitalization two times condition is mild, with brief episodes of based more on objective clinical per year for vomiting, refractory pain, findings, which are common indicators recurring symptoms once or twice gastrointestinal bleeding, perforation, yearly. Both sets of criteria for rating of disability, than on the pathologic obstruction, or penetration to liver, ulcer disease use subjective adjectives appearance of the gastric mucosa. pancreas, or colon. We propose a 30- such as ‘‘mild,’’ ‘‘moderate,’’ and We propose a 60-percent evaluation ‘‘pronounced’’ throughout the formulas. percent evaluation for either periodic or for any of the following: Periodic or Our consultants pointed out that constant dyspepsia with at least minor continuous dyspepsia with anemia due while ulcers may vary in location, they weight loss; or for hospitalization once to gastrointestinal bleeding; protein- produce the same array of symptoms, per year for vomiting, refractory pain, losing gastropathy with substantial and do not differ in functional gastrointestinal bleeding, perforation, weight loss and peripheral edema; or impairment. They suggested that all obstruction, or penetration to liver, hospitalization two or more times per types of ulcers be evaluated under the pancreas, or colon. We propose a 10- year for gastrointestinal bleeding, same criteria: the presence of symptoms percent evaluation for recurring intractable vomiting, or other and their response or lack of response dyspepsia that requires continuous complication of chronic gastritis. We to treatment, the extent of incapacitating treatment with prescription medication propose a 30-percent evaluation for or recurring episodes, and whether there for control. either of the following: Protein-losing is recurrent hematemesis (vomiting gastropathy with at least minor weight We also propose to add a note under blood) or melena, anemia, or weight loss, or hospitalization once per year for loss. We propose to adopt, with some the general rating formula for ulcer gastrointestinal bleeding, intractable modifications, their recommendations disease stating that the diagnosis of vomiting, or other complication of regarding bases of evaluations and to ulcer disease or duodenitis requires chronic gastritis. We propose a 10- evaluate all types of ulcer disease under confirmation on at least one occasion by percent evaluation for dyspepsia that the same criteria. We propose to provide imaging or . Because the requires continuous treatment with a single rating formula for gastric ulcer symptoms of ulcer disease are not prescription medication. (diagnostic code 7304), duodenal ulcer specific, the note would assure that the These proposed criteria are similar to (diagnostic code 7305), and marginal diagnosis of ulcer disease is not based those recommended by our consultants, (gastrojejunal) ulcer (diagnostic code on symptoms alone. but have been modified to remove

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subjective terms, and for the sake of within 30 minutes of eating, and a late propose a 100-percent evaluation for internal consistency. In order to type that occurs 90 minutes to 3 hours dumping syndrome that occurs after document that gastritis, which is often after eating (‘‘Harrison’s Principles of most meals, with substantial weight hard to diagnose, is definitely present, Internal Medicine’’ 1240 (Jean D. loss, malnutrition, and anemia. We we also propose to add a note stating Wilson, M.D. et al. eds., 12th ed. 1991)). propose a 60-percent evaluation for that evaluation under diagnostic code Although early and late types have dumping syndrome that occurs after 7307 requires that the diagnosis of different causes, their symptoms most meals, with substantial weight loss chronic gastritis be confirmed on at least overlap. Rather than experiencing a and anemia. We propose a 30-percent one occasion by endoscopy. The dumping syndrome, some individuals evaluation for dumping syndrome that condition of ‘‘gastritis, atrophic’’ is experience only severe diarrhea as a occurs daily or nearly so, despite listed in the current schedule at the end major postgastrectomy problem. Others treatment, with at least minor weight of the criteria for hypertrophic gastritis. experience abdominal pain, bilious loss. We propose a 10-percent It is followed by a statement that this is vomiting (vomiting of bile), anemia, and evaluation for intermittent dumping ‘‘a complication of a number of diseases, weight loss due to a condition called syndrome (occurring at least three times including pernicious anemia,’’ and a alkaline reflux gastritis (also called a week) requiring dietary restrictions. direction to rate the underlying biliary gastritis or bile reflux gastritis); Our consultants suggested criteria that condition. We propose to include this and some individuals have retain the same subjective terms of information in a second note under malabsorption and poor absorption of ‘‘infrequent,’’ ‘‘mild,’’ and ‘‘less diagnostic code 7307, to provide clear vitamins and minerals resulting in frequent,’’ as the current schedule. For guidance to the raters on how to malnutrition and anemia as their most example, our consultants recommended evaluate . significant problems (Yamada, 1394). that a 20-percent evaluation be assigned Since the signs and symptoms of for post-gastrectomy syndrome that is Postgastrectomy Syndromes (Diagnostic these postgastrectomy syndromes ‘‘mild’’ with ‘‘infrequent’’ episodes of Code 7308) overlap, and ‘‘dumping syndrome’’ is epigastric distress with ‘‘characteristic Postgastrectomy syndromes the commonly used designation for mild’’ circulatory symptoms or (diagnostic code 7308) are currently postgastrectomy signs and symptoms, continuous ‘‘mild’’ manifestations. We evaluated at levels of 60, 40, or 20 we propose to lump the various propose to use more specific terms such percent, based on frequency of episodes postgastrectomy syndromes together as as ‘‘after most meals’’ and ‘‘daily or of symptoms. A 60-percent evaluation is ‘‘dumping syndrome’’ and to add a note nearly so,’’ since making the criteria less assigned when the condition is severe, under diagnostic code 7308 stating that ambiguous is one of the goals of the meaning that it is associated with for purposes of evaluation under revision of the rating schedule. In order nausea, sweating, circulatory diagnostic code 7308, the term to make the criteria clear to everyone disturbance after meals, diarrhea, ‘‘dumping syndrome’’ includes who uses the rating schedule, we hypoglycemic symptoms, and weight symptoms that are associated with any propose to list the actual symptoms loss with malnutrition and anemia; a 40- of the following postgastrectomy (many of which overlap) of percent evaluation when the condition syndromes: Early and late types of hypoglycemia and circulatory is moderate, with less frequent episodes dumping syndrome, postgastrectomy disturbance in the note defining of epigastric disorders with diarrhea, and alkaline reflux gastritis. dumping syndrome, rather than use less characteristic mild circulatory These symptoms include any clear terms such as ‘‘hypoglycemic symptoms after meals but with diarrhea combination of , dizziness, symptoms’’ or ‘‘circulatory symptoms,’’ and weight loss; and a 20-percent lightheadedness, diaphoresis (sweating), as the consultants suggested. We also evaluation when the condition is mild, palpitations, tachycardia, postural propose a second note to direct raters to with infrequent episodes of epigastric hypotension, confusion, syncope separately evaluate complications, such distress with characteristic mild (fainting), nausea, vomiting (often with as osteomalacia, under an appropriate circulatory symptoms or continuous bile), diarrhea, (fatty stools), diagnostic code. mild manifestations. borborygmi (audible rumbling bowel Gastric Emptying Disorders (Diagnostic We propose to base evaluations of sounds), abdominal pain, anorexia (lack Code 7309) postgastrectomy syndromes on more or loss of appetite), abdominal bloating, objective criteria, such as the frequency and belching. In order to include both Diagnostic code 7309 is currently of dumping syndrome (which is the types of postgastrectomy dumping titled ‘‘stomach, stenosis of’’ and common term for the group of syndromes, we also propose to state, in includes an instruction to ‘‘[r]ate as for symptoms that may occur following the same note, that symptoms may gastric ulcer’’ (diagnostic code 7304), various types of surgery for ulcer occur immediately after eating or up to which in turn is usually rated as disease), whether there is weight loss, three hours later. duodenal ulcer (diagnostic code 7305). malnutrition or anemia, and whether a We propose to provide evaluation We propose to make diagnostic code restricted diet is needed. For the sake of levels of 100, 60, 30, and 10 percent, 7309 more inclusive by changing the simplicity, we propose to list the instead of the current 60, 40, and 20 title to ‘‘gastric emptying disorders possible signs and symptoms of percent. Our consultants suggested that (including (delayed gastric postgastrectomy syndromes in a note we add a 100-percent evaluation level, emptying), and pyloric, gastric, and rather than listing all possible since postgastrectomy syndromes may other motility disturbances)’’ because all manifestations at every evaluation level. be severely disabling, and we propose to of these conditions, which are not Several types of problems may occur do so. As with gastritis, to promote uncommon and are not currently listed after gastrectomy, with the onset, consistent evaluations, we propose to in the current rating schedule, may frequency, and types of symptoms substitute a 30-percent evaluation level produce similar signs and symptoms. varying with the particular type of for the 20- and 40-percent levels to We propose to provide evaluation surgery performed (Merck, 123). One provide a clearer distinction between levels of 100, 60, 30, and 10 percent for problem is the dumping syndrome. adjacent levels. We also propose to add diagnostic code 7309. As our There are two types of dumping a 10-percent evaluation level for milder consultants pointed out, these syndrome, an early type that occurs cases of dumping syndrome. We conditions can be very debilitating. We

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propose to base the evaluation on Disease or Injury Although the current evaluation criteria specific to gastric emptying (Diagnostic Code 7314) levels for these conditions are limited to disorders—epigastric pain or fullness, 30, 10, and zero percent, we propose to anorexia (lack or loss of appetite), Diagnostic code 7314 is currently provide evaluation levels of 100, 60, 30, nausea, vomiting, gastroesophageal titled ‘‘, chronic’’ and has and 10 percent for biliary tract disease reflux, early satiety (feeling that hunger evaluation levels of 30, 10, and zero or injury, to accommodate more severe and thirst are satisfied), and abdominal percent. A 30-percent evaluation is cases, including those that are totally bloating (Yamada, 1264). We propose to assigned if the condition is severe, with disabling. We propose to base add a note listing the signs and frequent attacks of gall bladder colic; a evaluations on the frequency of acute symptoms of gastric emptying disorders, 10-percent evaluation if the condition is attacks of signs and symptoms of biliary for purposes of evaluation under moderate, with gall bladder dyspepsia, tract disease or injury per year; the diagnostic code 7309. confirmed by X-ray technique, and with frequency of hospitalizations for biliary infrequent attacks (not over two or three We propose a 100-percent evaluation tract disease or injury per year; the a year) of gall bladder colic, with or for daily or near-daily signs and response to medical or surgical without jaundice; and a zero-percent symptoms with substantial weight loss treatment; and whether is evaluation if the condition is mild. and malnutrition. We propose a 60- present. We propose to describe the percent evaluation for periodic or daily Chronic cholelithiasis (diagnostic usual signs and symptoms of biliary or near-daily signs and symptoms with code 7315) and chronic cholangitis tract disease and injury in a note, as substantial weight loss. We propose a (diagnostic code 7316) are evaluated discussed below. 30-percent evaluation for periodic signs under the same criteria as chronic We propose a 100-percent evaluation and symptoms with minor weight loss. cholecystitis. All of these conditions are for any of the following: Near-constant We propose a 10-percent evaluation for closely related and may co-exist, and debilitating attacks of biliary tract periodic signs and symptoms without can readily be evaluated under a single disease or injury that are refractory to medical or surgical treatment; liver weight loss, but requiring continuous diagnostic code and set of evaluation failure; or hospitalization three or more treatment with prescription medication. criteria. In addition, diagnostic code times per year for biliary tract disease or These criteria are specific to the 7318, ‘‘Gall bladder, removal of,’’ can injury. We propose a 60-percent disability and are clearer and more result in signs and symptoms similar to evaluation for either of the following: objective than those proposed by our those of the above three conditions. It is Six or more attacks of biliary tract consultants. While the consultants used currently evaluated at 30, 10, or zero disease or injury per year, partially similar symptoms, they also included percent, under subjectively-defined responsive to treatment; or modifiers like ‘‘pronounced,’’ ‘‘severe,’’ criteria. A 30-percent evaluation is hospitalization two times per year for and ‘‘moderate,’’ which are subjective assigned if there are ‘‘severe biliary tract disease or injury. We terms that we are trying to exclude from symptoms,’’ a 10-percent evaluation if there are ‘‘mild symptoms,’’ and a zero- propose a 30-percent evaluation for the rating schedule when possible, for either of the following: Three to five the sake of consistent evaluations. percent evaluation if the condition is nonsymptomatic. ‘‘Gall bladder, injury attacks of biliary tract disease or injury Injury of the Stomach (Diagnostic Code of’’ (diagnostic code 7317) is currently per year, or hospitalization once per 7310) rated as peritoneal adhesions. year for biliary tract disease or injury. We propose a 10-percent evaluation for Injury of the stomach, diagnostic code We, therefore, propose to revise the either of the following: One or two 7310, is currently evaluated under the title of diagnostic code 7314 to the more attacks of biliary tract disease or injury criteria for peritoneal adhesions inclusive ‘‘Biliary tract disease or injury per year; or biliary tract pain occurring (diagnostic code 7301). We propose to (chronic cholecystitis, cholelithiasis, at least monthly, despite medical retain that direction and to add an choledocholithiasis, chronic cholangitis, treatment. We propose to remove the alternative direction, as recommended status post-, gall zero-percent level as unnecessary (see by our consultants, to evaluate as bladder or injury, biliary § 4.31). postgastrectomy syndromes (diagnostic dyskinesia, cholesterolosis, polyps of The proposed criteria would provide code 7308) if the injury required a gall bladder, sclerosing cholangitis, more objective criteria for evaluating gastric resection. stricture or infection of the bile ducts, these conditions and also provide a choledochal cyst)’’ because all of these wider range of percentage evaluations, conditions are related and may produce consistent with the potential disabling In a separate rulemaking, we similar effects. It is therefore effects of these conditions. previously revised the portion of § 4.114 appropriate to evaluate them under the We propose to add four notes under that addresses liver disease, including same criteria. It is not uncommon for diagnostic code 7314, with the first injury of the liver (diagnostic code more than one of these conditions to be stating that for purposes of evaluation 7311), cirrhosis of the liver (diagnostic present at the same time, and using a under diagnostic code 7314, attacks of code 7312), deletion of residuals of single set of criteria would better allow biliary tract disease or injury include abscess of liver (diagnostic code 7313), an appropriate overall evaluation in any combination of such signs and infectious hepatitis (diagnostic code those cases, since the signs and symptoms as abdominal pain (including 7345), benign new growths of the symptoms overlap and may be identical. ), dyspepsia, jaundice, digestive system (7344), and malignant Our consultants did not suggest anorexia (lack or loss of appetite), new growths of the digestive system, combining these conditions under a nausea, vomiting, chills, and exclusive of skin growths (diagnostic single diagnostic code, as we are (Merck, 242–245). So that the presence code 7343). Following notice and proposing, but did suggest evaluating of biliary tract disease is substantiated, comment, this rulemaking was them under the same criteria. The and not based on symptoms alone, the published as a final rule on May 31, evaluation criteria we are proposing are second proposed note would state that 2001 (66 FR 29486). We do not propose similar to those they suggested, but evaluation under diagnostic code 7314 any further changes to those diagnostic would eliminate the subjective terms requires that the diagnosis of any of codes. ‘‘severe,’’ ‘‘moderate’’ and ‘‘mild’’. these conditions be confirmed by X-ray

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or other imaging procedure, laboratory evaluation is assigned if the condition is evaluation is assigned if the condition is findings, or other objective evidence. mild, with ‘‘disturbances of bowel moderate, with infrequent The third proposed note would direct function with occasional episodes of exacerbations. raters to separately evaluate peritoneal abdominal distress.’’ Our consultants The most common symptoms of adhesions (diagnostic code 7301) if suggested evaluation levels of 30 and 10 ulcerative are abdominal pain applicable, and combine (under the percent, with essentially the same and bloody diarrhea, but there may also provisions of § 4.25) with an evaluation criteria as the current ones, except for be , fever, tachycardia, under diagnostic code 7314, as long as adding ‘‘refractory to medical anorexia, malaise, weakness, and other the same findings are not used to treatment’’ to the criteria for 30 percent, symptoms. In severe cases, there may be support more than one evaluation. This and ‘‘partially responsive to treatment’’ weight loss, malnutrition, anemia, and would assure that traumatic or to the criteria for 10 percent. We are hypoalbuminemia. Common postoperative manifestations due to proposing to remove the subjective complications include perforation, adhesions would be properly evaluated. terms ‘‘severe,’’ ‘‘frequent,’’ stricture, hemorrhage, dehydration, The fourth proposed note would direct ‘‘occasional,’’ etc., from the criteria and fulminant (sudden and intense) colitis, raters to evaluate the cirrhotic phase of to base evaluation on more objective and toxic (a severe sclerosing cholangitis under diagnostic criteria, in order to decrease the reliance distention of the colon that can be life code 7312 (cirrhosis of liver), a more on ambiguous descriptive terms. We threatening). Among other possible appropriate diagnostic code for propose a 30-percent evaluation for complications are liver disease, skin evaluating that condition than 7314. daily or near-daily disturbances of nodules, eye problems, colon cancer, Since chronic cholelithiasis (current bowel function (diarrhea, or alternating and arthritis (Merck, 155–156 and diagnostic code 7315), chronic diarrhea and constipation), bloating, http://digestive.niddk.nih.gov/ cholangitis (current diagnostic code and abdominal cramping or pain, ddiseases/pubs/colitis/ 7316), injury of gall bladder (current refractory to medical treatment, and a index.htm#symptoms, National diagnostic code 7317), and removal of 10-percent evaluation for disturbances Digestive Diseases Information gall bladder (current diagnostic code of bowel function (diarrhea, or Clearinghouse, February 2006). 7318) would all be included in alternating diarrhea and constipation), Our consultants suggested we diagnostic code 7314, for reasons bloating, and abdominal cramping or continue evaluations based on discussed above, we propose to delete pain that occur three or more times a frequency of episodes, attacks, and the separate diagnostic codes for those month and that respond partially to exacerbations, and they provided some conditions. medical treatment. We propose to timeframes for their frequency and duration. We propose to use their Disease or Injury of the Spleen remove the zero-percent level as unnecessary (see § 4.31). These suggestions, in a modified form, There is currently a reference to proposed criteria would ensure removing the subjective language such disease or injury of the spleen under consistency of evaluations and still be as ‘‘severe’’ and ‘‘marked’’ that they diagnostic code 7318, directing raters to in keeping with our consultants’ included. We also further propose to the hemic and lymphatic systems. We recommendations. specify the usual symptoms of propose to remove that reference as in the criteria, with unnecessary, since the spleen, although Amebiasis and Bacillary bloody diarrhea being the major in the abdominal cavity, is part of the In the current rating schedule, symptom, and to include criteria based lymphatic, not the digestive system. diagnostic code 7321 is amebiasis, and on the need for hospitalization for Evaluation criteria for splenectomy diagnostic code 7322 is bacillary complications or continuous treatment (diagnostic code 7706) and healed dysentery. Both conditions are with prescription medication. We injury of the spleen (diagnostic code uncommon today except as acute short- propose a 100-percent evaluation for 7707) are included in the hemic and term illnesses. They ordinarily resolve either of the following: malnutrition, lymphatic portion of the rating schedule without residuals because they are substantial weight loss, anemia, and (38 CFR 4.117), and both conditions are highly responsive to modern drug general debility with multiple attacks of listed in the index to the rating schedule treatment. In accordance with our colitis per year, with bloody diarrhea, as part of the hemic and lymphatic consultants’ suggestion, we therefore abdominal or rectal pain, fever, and systems. propose to delete diagnostic code 7321 malaise; or hospitalization three or more and diagnostic code 7322 as times per year for complications such as (Diagnostic unnecessary. hemorrhage, dehydration, obstruction, Code 7319) fulminant (sudden and intense) colitis, Ulcerative Colitis (Diagnostic Code Diagnostic code 7319 is currently , or perforation. titled ‘‘Irritable colon syndrome (spastic 7323) We propose a 60-percent evaluation colitis, mucous colitis, etc.).’’ We Ulcerative colitis (diagnostic code for either of the following: substantial propose to retitle it ‘‘Irritable bowel 7323) is currently evaluated at 100, 60 weight loss and anemia, with multiple syndrome (irritable colon, spastic 30, or 10 percent. A 100-percent attacks of colitis per year, with bloody colitis, mucous colitis),’’ since this is evaluation is assigned if the condition is diarrhea, abdominal or rectal pain, current terminology for the condition. pronounced, resulting in marked fever, and malaise; or hospitalization The current evaluation levels are 30, 10, malnutrition, anemia, and general two times per year for complications and zero percent. A 30-percent debility, or if there are serious such as hemorrhage, dehydration, evaluation is assigned if the condition is complications, such as . A obstruction, fulminant colitis, toxic severe, with diarrhea or alternating 60-percent evaluation is assigned if the megacolon, or perforation. We propose diarrhea and constipation, with more or condition is severe, with numerous a 30-percent evaluation for either of the less constant abdominal distress. A 10- attacks a year and malnutrition, with the following: three or more attacks of percent evaluation is assigned if the health only fair during remissions. A 30- colitis (each lasting 5 or more days) per condition is moderate, with frequent percent evaluation is assigned if the year, with diarrhea with blood, pus, or episodes of bowel disturbance with condition is moderately severe, with mucous, and abdominal or rectal pain; abdominal distress. A zero-percent frequent exacerbations; and a 10-percent or hospitalization one time per year for

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complications such as hemorrhage, and on whether continuous treatment treatment, and one or two episodes per dehydration, obstruction, fulminant with prescription medication is year of fluid and electrolyte imbalance colitis, toxic megacolon, or perforation. required. We propose to delete the zero- requiring parenteral (intravenous or We propose a 10-percent evaluation for percent level, since a parasitic infection intramuscular) hydration. We propose a either of the following: One or two that does not meet the criteria for a ten- 10-percent evaluation if the condition attacks of colitis (each lasting 5 or more percent evaluation would be assigned a requires continuous treatment with days) per year with diarrhea with blood, non-compensable evaluation, and this is prescription medication for control. pus, or mucous, and abdominal or rectal sufficiently clear without the need for a These criteria for evaluating chronic pain; or continuous treatment with zero-percent evaluation level (see diarrhea of unknown etiology are both prescription medication either to § 4.31). objective and specific to the disability, control symptoms or to maintain We propose to evaluate parasitic and are in general agreement with the remission. of the intestinal tract at 30 suggestions of our consultants, although We also propose to add a note percent if there is daily diarrhea they recommended that we require at directing raters to evaluate other (occurring more than three times per least six watery bowel movements per complications, such as uveitis, day) and abdominal pain, with at least day, instead of five or more, as we are ankylosing spondylitis, sclerosing minor weight loss. We propose to proposing. In our judgment, five or more cholangitis, etc., separately under an evaluate them at 10 percent if diarrhea watery bowel movements a day appropriate diagnostic code. We and abdominal pain occur, and they constitute a sufficient indication of propose to add a second note directing require continuous treatment with severity of the major disabling symptom raters, if there has been a colon prescription medication for control. In of this condition. The consultants also resection, to evaluate under diagnostic addition, since parasitic infection of the recommended a 60-percent evaluation codes 7350 (colostomy or ileostomy) may result in a for one episode of biochemical and 7329 (resection of ), malabsorption syndrome, we propose to alteration, but it is our opinion that one as applicable, and to combine the add a note directing raters to evaluate episode would not be sufficiently evaluations under the provisions of under proposed diagnostic code 7353 disabling to warrant a 60-percent § 4.25, as long as the same findings are (malabsorption syndrome), if evaluation, in comparison to other not used to support more than one malabsorption is present, and doing so disabilities evaluated at a 60-percent evaluation. would result in a higher evaluation. level. We propose instead that there be three or more episodes of fluid and Intestinal Parasitic Infections Chronic Diarrhea of Unknown Etiology electrolyte imbalance to warrant a 60- (Diagnostic Code 7324) (Diagnostic Code 7325) percent evaluation, and one or two We propose to change the title of Diagnostic code 7325 is currently episodes to warrant a 30-percent diagnostic code 7324 from ‘‘distomiasis, titled ‘‘, chronic’’ and directs evaluation. intestinal or hepatic’’ to ‘‘parasitic that the condition be rated as irritable infections of the intestinal tract’’ colon syndrome (diagnostic code 7319). Crohn’s Disease (Diagnostic Code 7326) because our consultants advised us that At the suggestion of our consultants, we Diagnostic code 7326 is currently distomiasis (formerly used to refer to propose to revise the title to ‘‘chronic titled ‘‘, chronic’’ and trematodes or flukes) is a term that is no diarrhea of unknown etiology’’ because directs that the condition be rated as longer used. The generic term ‘‘parasitic chronic enteritis is no longer considered irritable colon syndrome (diagnostic infections’’ includes all types of a specific diagnostic entity. We also code 7319), with evaluation levels of 30, parasitic infections, not just trematodes propose to provide evaluation criteria 10, and zero-percent, but as suggested or flukes. Parasitic infections that do not specific to this condition, in accordance by our consultants, we propose to primarily affect the digestive tract are with the recommendation of our change the title to ‘‘Crohn’s disease,’’ evaluated in the portion of the rating consultants, since those for evaluating the current medical term for this schedule that addresses Infectious irritable colon syndrome (which include condition, and to provide criteria more Diseases, Immune Disorders and ‘‘alternating constipation and diarrhea’’) specific to the disabling effects of this Nutritional Deficiencies. The current are not appropriate for evaluating disease. Our consultants pointed out evaluation criteria, with levels of 30, 10, chronic diarrhea. that Crohn’s disease can be very and zero percent, are based on whether We propose to provide evaluation disabling, and we therefore propose to there are ‘‘severe,’’ ‘‘moderate,’’ or levels of 60, 30, and 10 percent (our provide a broader range of evaluation ‘‘mild’’ symptoms, with no specific consultants recommended levels of 60 levels—100, 60, 30, and 10 percent—in guidance as to the type of symptoms. and 30 percent) based on the frequency order to encompass the whole range of Our consultants suggested criteria of of watery bowel movements, their disabling effects that may result from ‘‘severe symptoms including diarrhea, requirement for and response to medical this condition. The most common signs abdominal distress, and weight loss, treatment, and on the number of and symptoms of Crohn’s disease, refractory to medical treatment’’ for a episodes per year of fluid and which is often episodic, include 30-percent evaluation and ‘‘moderate electrolyte imbalance requiring diarrhea, abdominal pain and symptoms’’ for a 10-percent evaluation. parenteral (intravenous or tenderness, fever, anorexia, and weight While more specific than the current intramuscular) hydration. We propose a loss; also there may be pallor, weakness, criteria, they retain subjective language. 60-percent evaluation if there are five or malnutrition, , , bowel We propose to remove the subjective more watery bowel movements daily, obstruction, and other complications, as terms and base evaluation on the refractory to medical treatment, and pointed out by our consultants, and as presence of diarrhea (which commonly three or more episodes per year of fluid found in standard medical books means more than three loose watery and electrolyte imbalance requiring (Merck, 153; Yamada, 1599). stools in one day (http:// parenteral (intravenous or We propose a 100-percent evaluation digestive.niddk.nih.gov/ddiseases/pubs/ intramuscular) hydration. We propose a for either of the following: multiple diarrhea/, National Digestive Diseases 30-percent evaluation if there are five or attacks or flareups of Crohn’s disease Information Clearinghouse, October more watery bowel movements daily, per year with abdominal pain or 2003)), abdominal pain, and weight loss, partially responsive to medical tenderness, diarrhea, fever, anorexia

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(lack or loss of appetite), and fatigue 7350 (colostomy or ileostomy) if an diarrhea), requiring outpatient treatment plus malnutrition, substantial weight ostomy is present, and under diagnostic with a course of antibiotics, bed rest, loss, hypoalbuminemia, and anemia; or code 7328 (resection of the small and a liquid diet; hospitalization one hospitalization three or more times per intestine) or 7329 (resection of large time per year for complications such as year for complications such as abscess, intestine), if applicable, as long as the abscess, perforation, obstruction, or stricture, obstruction, or fistula. same findings are not used to support fistula; or hospitalization once or twice We propose a 60-percent evaluation more than one evaluation. per year for acute for any of the following: multiple requiring intravenous antibiotics. attacks or flareups of Crohn’s disease Diverticulitis (Diagnostic Code 7327) We propose a 10-percent evaluation per year with abdominal pain or The current rating schedule does not for the following: One or two attacks of tenderness, diarrhea, fever, anorexia provide specific criteria for diverticulitis per year with abdominal (lack or loss of appetite), and fatigue diverticulitis, diagnostic code 7327, but pain and tenderness, fever, and irregular plus substantial weight loss and anemia; directs that it be evaluated as either defecation (constipation, diarrhea, or hospitalization two times per year for irritable colon syndrome (diagnostic alternating constipation and diarrhea), recurrent complications such as abscess, code 7319), peritoneal adhesions requiring a course of antibiotics. stricture, obstruction, or fistula; or (diagnostic code 7301), or ulcerative We also propose to add a note to constant or near-constant treatment with colitis (diagnostic code 7323), address evaluation after surgery, which high dose systemic (oral or parenteral depending on the predominant is often needed to treat diverticulitis. [intravenous or intramuscular]) disability picture. We propose to The note would direct raters to evaluate . provide evaluation criteria specific to under diagnostic code 7350 (colostomy We propose a 30-percent evaluation this condition, with evaluation levels of or ileostomy) if an ostomy is present, for any of the following: three or more 100, 60, 30, and 10 percent, to reflect its and under diagnostic code 7329 attacks or flareups of Crohn’s disease range of severity. The most common (resection of large intestine), if per year with abdominal pain or signs and symptoms of diverticulitis are applicable, as long as the same findings tenderness, diarrhea, fever, anorexia abdominal pain and tenderness, fever, are not used to support more than one (lack or loss of appetite), and fatigue, and an elevated white blood count evaluation (see § 4.14). plus at least minor weight loss; (Merck, 160; Yamada, 1737). There may These criteria are similar to those hospitalization one time per year for also be peritoneal irritation, with or suggested by our consultants, but complications such as abscess, stricture, without bleeding; irregular defecation; modified, to remove indefinite terms obstruction, or fistula; or three or more and such complications as fistula such as ‘‘severe,’’ ‘‘moderate,’’ and (but not constant) courses of treatment formation, intestinal obstruction, ‘‘frequent,’’ and to substitute criteria per year with high dose systemic (oral abscess formation, or perforation. that are both more specific and more or parenteral [intravenous or Milder attacks can be treated with objective, in order to promote consistent intramuscular]) corticosteroids. antibiotics, bed rest, and a liquid diet as evaluations. We propose a 10-percent evaluation an outpatient, but more serious attacks Resection of (Diagnostic for any of the following: One or two may require hospitalization for Code 7328) attacks or flareups of Crohn’s disease intravenous antibiotics and other per year with abdominal pain or measures, and, sometimes, surgery. Resection of the small intestine, tenderness, diarrhea, and fever; one or We therefore propose a 100-percent diagnostic code 7328, currently has two courses of treatment per year with evaluation for either of the following: evaluation levels of 60, 40 and 20 high dose systemic (oral or parenteral near-constant signs and symptoms of percent, with criteria for the various [intravenous or intramuscular]) diverticulitis, with abdominal pain and levels based on the extent of corticosteroids; or continuous treatment tenderness, fever, and irregular interference with absorption and with prescription medication other than defecation (constipation, diarrhea, or nutrition, the degree of impairment of high dose systemic (oral or parenteral alternating constipation and diarrhea); health with either weight loss or [intravenous or intramuscular]) or hospitalization at least three times inability to gain weight, and whether corticosteroids. per year for complications such as there are symptoms. A 60-percent These criteria are more specific to abscess, perforation, obstruction, or evaluation is assigned if the condition Crohn’s disease than those in the fistula. shows marked interference with current rating schedule, and represent We propose a 60-percent evaluation absorption and nutrition, manifested by modifications of the criteria suggested for any of the following: six or more severe impairment of health objectively by our consultants (for example, to attacks of diverticulitis per year with supported by examination findings remove subjective language). They abdominal pain and tenderness, fever, including material weight loss; a 40- would provide a clear and objective and irregular defecation (constipation, percent evaluation if the condition basis for evaluation, as well as a suitable diarrhea, or alternating constipation and produces definite interference with range of evaluation levels. diarrhea), requiring outpatient treatment absorption and nutrition, manifested by We also propose to add a note with a course of antibiotics, bed rest, impairment of health objectively directing raters to evaluate and a liquid diet; hospitalization two supported by examination findings, complications, such as external times per year for complications such as including definite weight loss; and a 20- gastrointestinal fistula, arthritis, abscess, perforation, obstruction, or percent evaluation if the condition is episcleritis (inflammation of the outer fistula; or hospitalization three or more symptomatic, with diarrhea, anemia, layers of the sclera of the eye), etc., times per year for acute diverticulitis and inability to gain weight. These separately under an appropriate requiring intravenous antibiotics. criteria contain indefinite criteria, such diagnostic code as long as the same We propose a 30-percent evaluation as ‘‘material’’ or ‘‘definite’’ weight loss findings are not used to support more for any of the following: three to five and ‘‘marked’’ or ‘‘definite’’ interference than one evaluation (see § 4.14). We attacks of diverticulitis per year with with absorption. In addition, our propose to add a second note, because abdominal pain and tenderness, fever, consultants advised us that the current bowel surgery is often needed, directing and irregular defecation (constipation, criteria, based partly on weight loss or raters to evaluate under diagnostic code diarrhea, or alternating constipation and inability to gain weight, are no longer

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appropriate because the parenteral subjective terms and provide more External Gastrointestinal Fistula (intravenous or intramuscular) and objective criteria based on the primary (Diagnostic Code 7330) supplemental nutrition now available symptoms of diarrhea and abdominal will ordinarily allow body weight to be pain and the number of complications, Diagnostic code 7330 is currently maintained. They pointed out that the as recommended by our consultants. We titled ‘‘Intestine, fistula of, persistent, or type and frequency of nutritional propose that there be a broader range of after attempt at operative closure.’’ External gastrointestinal support needed is related to the severity evaluation levels, 100, 60, 30, and 10 (fistulas that drain from the of the condition. percent, consistent with the range of We therefore propose to provide gastrointestinal tract to the surface of severity of the condition. evaluation criteria that are both more the skin) other than fistulas from the objective and more characteristic of the We propose a 100-percent evaluation intestine are not currently included in disabling effects of resection of the for multiple daily episodes of diarrhea the rating schedule. Our consultants small intestine than the current criteria, and abdominal pain that are refractory stated that the symptoms and in light of modern medicine. We to treatment, plus at least two complications of external propose that the condition be evaluated hospitalizations per year for gastrointestinal fistula include fluid based on the need for oral or parenteral complications such as obstruction, discharge, skin problems, fluid and (intravenous or intramuscular) fistula, or abscess; a 60-percent electrolyte imbalance, recurrent sepsis, nutritional support and on the presence evaluation for multiple attacks of and malnutrition. We propose to base of diarrhea and other symptoms. Our diarrhea and abdominal pain per year the evaluation on such manifestations, consultants said that the need for total requiring medical treatment plus at least regardless of the type of discharge, parenteral (intravenous or one hospitalization per year for rather than solely on the presence and intramuscular) nutrition indicates a complications such as obstruction, amount of the discharge. Only fecal debilitating condition that would be fistula, or abscess; a 30-percent discharge is currently evaluated under totally disabling. We therefore propose evaluation for four or more attacks of this diagnostic code, and the criteria do a 100-percent evaluation if total diarrhea and abdominal pain per year not take into account the type of parenteral (intravenous or requiring medical treatment; and a 10- treatment or the potential specific intramuscular) nutrition is required. We effects that might result from fecal or propose a 60-percent evaluation for percent evaluation for two or three attacks per year of diarrhea and other types of discharges. As diarrhea, weakness, fatigue, abdominal recommended by our consultants, we abdominal pain requiring medical cramps, and bloating, with anemia, propose to expand the category of fistula treatment. These criteria are more requiring daily (oral) nutritional of the intestine and change the title to supplementation, plus parenteral objective and would therefore promote ‘‘external gastrointestinal fistula (intravenous or intramuscular) nutrition more consistent evaluations, and they (including biliary, pancreatic, for a total of at least 28 days per year; are consistent with the disabling effects esophageal, gastric, and intestinal a 30-percent evaluation for diarrhea, that sometimes occur after large bowel fistulas)’’ in order to include all external weakness, fatigue, abdominal cramps, resection. They are similar to the fistulas of gastrointestinal origin. The and bloating requiring daily (oral) suggestions of our consultants, but with current criteria are ‘‘copious and nutritional supplementation plus less subjective language and with frequent, fecal discharge’’ for a 100- parenteral (intravenous or modifications of the criteria at various percent evaluation; ‘‘constant or intramuscular) nutrition for a total of at levels, for the sake of internal frequent, fecal discharge’’ for a 60- least 14 days, but less than 28 days per consistency. percent evaluation; and ‘‘slight year; and a 10-percent evaluation for Although the current note following infrequent, fecal discharge’’ for a 30- diarrhea, weakness, fatigue, abdominal percent evaluation. The current cramps, and bloating requiring daily diagnostic code 7329 instructs raters to evaluate the condition as peritoneal provision also directs that if healed, (oral) nutritional supplementation. fistulas are to be rated as peritoneal We propose to modify the current adhesions, diagnostic code 7301, if adhesions. We propose to delete the note under diagnostic code 7328. It now adhesions are the predominant ambiguous and subjective terms directs that the condition be rated under disability, we propose to direct raters to ‘‘slight,’’ ‘‘frequent,’’ and ‘‘infrequent,’’ diagnostic code 7301, where residual separately evaluate peritoneal adhesions and replace them with more objective adhesions constitute the predominant (diagnostic code 7301), if applicable, and specific criteria, in order to assure disability. We propose that the note and combine (under the provisions of more consistent evaluations. We also instruct raters to separately evaluate § 4.25) with an evaluation under propose to delete the reference to fecal peritoneal adhesions, diagnostic code diagnostic code 7329, as long as the discharge because we are proposing that 7301, if applicable, as long as the same same findings are not used to support this diagnostic code include fistulas findings are not used to support an more than one evaluation. This is where the discharge may be bile, gastric evaluation both under diagnostic code clearer and more appropriate, since fluid, etc., instead of fecal material. We 7301 and under diagnostic code 7328. evaluation under both cited diagnostic also propose to delete the direction to Resection of Large Intestine (Diagnostic codes is feasible under certain rate healed fistulas as peritoneal Code 7329) circumstances (see § 4.14, Avoidance of adhesions, since our consultants said Resection of the large intestine, pyramiding). We also propose to add a that adhesions are not a usual diagnostic code 7329, currently has second note directing raters to evaluate complication of fistulas. evaluation levels of 40, 20, and 10 under diagnostic code 7350 (colostomy Our consultants stated that the percent, based on the indefinite criteria or ileostomy), if applicable, and symptoms and complications of external of whether symptoms are ‘‘severe’’ and combine (under the provisions of § 4.25) gastrointestinal fistula include fluid ‘‘objectively supported by examination with an evaluation under diagnostic discharge, skin problems, fluid and findings’’ (for 40 percent), ‘‘moderate’’ code 7329, as long as the same findings electrolyte imbalance, recurrent sepsis, (for 20 percent), or ‘‘slight’’ (for 10 are not used to support more than one and malnutrition. We propose to base percent). We propose to remove these evaluation. the evaluation on such manifestations,

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rather than simply on the extent and tuberculous peritonitis be evaluated material. We propose to remove the frequency of fecal discharge. under §§ 4.88b or 4.89 (of this part). We zero-percent level as unnecessary (see We propose a 100-percent evaluation propose to correct this reference because § 4.31). These more objective and for external gastrointestinal fistula if § 4.88b was redesignated § 4.88c in a condition-specific criteria would there is constant or near-constant separate rulemaking (59 FR 60902), promote consistent evaluations of this copious discharge that cannot be which was published in the Federal disability and are in general agreement contained, and any of the following is Register on November 29, 1994. The with, although more detailed than, the present: A need for total parenteral correct section references should be revisions suggested by our consultants. (intravenous or intramuscular) 4.88c and 4.89. Otherwise, we propose They also exclude the subjective terms nutritional support, malnutrition, seven no change to the rating criteria, but we such as ‘‘pronounced’’ and ‘‘moderate’’ or more episodes per year of fluid and do propose to simplify the title of this that our consultants used. We also electrolyte imbalance requiring diagnostic code to ‘‘Tuberculous propose to add a note directing raters to parenteral (intravenous or peritonitis.’’ evaluate under diagnostic code 7350 intramuscular) hydration, or two or (colostomy or ileostomy) if an ostomy is Impaired Control of the Anal Sphincter more episodes per year of sepsis (a present, since fecal incontinence may (Diagnostic Code 7332) serious and sometimes life-threatening require a colostomy. infection with a widespread Diagnostic code 7332 is currently inflammatory response). We propose a titled ‘‘ and anus, impairment of Stricture of the Anus (Diagnostic Code 60-percent evaluation for constant or sphincter control.’’ We propose to 7333) near-constant copious discharge that change the title to ‘‘Impaired control of Diagnostic code 7333 is currently cannot be contained, and with any of the anal sphincter (anal incontinence)’’ titled ‘‘Rectum and anus, stricture of.’’ the following: Persistent skin for more accuracy, because our Because our consultants suggested that breakdown, despite treatment, five or consultants stated that inclusion of the rectal strictures would be more six episodes per year of fluid and rectum in this category is not appropriately evaluated with bowel electrolyte imbalance requiring appropriate, since the sphincter is strictures under diagnostic code 7349, parenteral (intravenous or actually an anal, rather than a rectal, we propose to remove rectal strictures intramuscular) hydration, or one structure. There are currently evaluation from this diagnostic code and change episode of sepsis per year. We propose levels of 100, 60, 30, 10 and zero the title to ‘‘Stricture of the anus.’’ The a 30-percent evaluation for constant or percent. A 100-percent evaluation is current evaluation criteria are intermittent discharge with either of the assigned if there is complete loss of ‘‘requiring colostomy,’’ for a 100-percent following: Six or more episodes per year sphincter control; a 60-percent evaluation; ‘‘great reduction of lumen, of skin breakdown requiring treatment, evaluation if there is extensive leakage or extensive leakage,’’ for a 50-percent or two to four episodes per year of fluid and fairly frequent involuntary bowel evaluation; and ‘‘moderate reduction of and electrolyte imbalance requiring movements; a 30-percent evaluation if lumen, or moderate constant leakage,’’ parenteral (intravenous or there are occasional involuntary bowel for a 30-percent evaluation. We propose intramuscular) hydration. We propose a movements necessitating wearing of to remove the indefinite terms, such as 10-percent evaluation for constant or pad; a 10-percent evaluation if there is ‘‘great,’’ ‘‘extensive,’’ and ‘‘moderate,’’ intermittent discharge with either of the constant slight, or occasional moderate and base the evaluation on objective following: At least two, but less than leakage; and a zero-percent evaluation if criteria, such as the extent of reduction six, episodes per year of skin breakdown the condition is healed or slight, of the lumen, the frequency and extent requiring treatment, or one episode per without leakage. These criteria contain of fecal soiling, and the necessity for year of fluid and electrolyte imbalance numerous indefinite terms, such as daily wearing of absorbent material. requiring parenteral (intravenous or ‘‘extensive,’’ ‘‘frequent,’’ ‘‘occasional,’’ Because we are proposing a separate intramuscular) hydration. and ‘‘slight,’’ that allow different diagnostic code for the evaluation of The proposed criteria are more individuals to make different colostomy and ileostomy, there is no precise and better take into account the interpretations of the criteria. longer a need to include colostomy in actual disabling effects of a fistula. We propose to retain evaluation levels these criteria. We propose to change the These changes would provide raters of 100, 60, 30, and 10 percent, but omit current evaluation levels of 100, 50, and with clearly delineated objective criteria the zero-percent evaluation level as 30 percent to 100, 60, and 30 percent, for evaluation and are in general unnecessary (see § 4.31). We further and to add a 10-percent level, for the agreement with revisions suggested by propose to make the criteria more sake of more internal consistency. These our consultants. Our consultants objective by basing them on the specific are also the levels we propose to recommended that we direct raters to frequency of fecal soiling, the extent of provide for diagnostic code 7332, and evaluate internal gastrointestinal fistulas inability to control solid or liquid feces, the type and range of disability due to (fistulas that drain from one area of the and the need for wearing absorbent this condition are very similar to those gastrointestinal tract to another) under material. We propose a 100-percent of disability due to impaired control of the criteria for malabsorption evaluation if there is complete inability the anal sphincter. We propose a 100- (diagnostic code 7353) or other to control solid and liquid feces; a 60- percent evaluation if there is inability to appropriate condition, depending on the percent evaluation if there is daily fecal open or completely close the anus, with particular findings, since malabsorption soiling and complete inability to control complete inability to control liquid or is a common effect of internal fistulas. liquid feces; a 30-percent evaluation if solid feces. We propose a 60-percent We propose to add this direction in a there is fecal soiling that, although less evaluation if there is reduction of the note under diagnostic code 7330. than daily, is frequent enough or lumen by at least 50 percent, with pain extensive enough to require daily and prolonged straining during Tuberculous Peritonitis (Diagnostic wearing of absorbent material; and a 10- defecation, and complete inability to Code 7331) percent evaluation if there is fecal control liquid feces. We propose a 30- Diagnostic code 7331, ‘‘peritonitis, soiling that is intermittent, and not percent evaluation if there is reduction tuberculous, active or inactive,’’ frequent enough or extensive enough to of the lumen, but by less than 50 currently directs that inactive require daily wearing of absorbent percent, with straining during

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defecation, and fecal incontinence that without complete inability to control and we propose to add those names to requires daily wearing of absorbent liquid or solid feces during periods of the title. We propose a 100-percent material; and a 10-percent evaluation if prolapse, but with difficulty in bowel evaluation for fistula in ano with there is reduction of the lumen, with evacuation and fecal soiling that is constant or near-constant abscesses with fecal soiling that is not frequent enough frequent enough or extensive enough to drainage and pain that are refractory to or extensive enough to require daily require daily wearing of absorbent medical and surgical treatment; a 60- wearing of absorbent material. material; and a 10-percent evaluation if percent evaluation for four or more Because a colostomy may be required there is intermittent prolapse with abscesses (each lasting a week or more) for treatment of this condition, we also difficulty in bowel evacuation and fecal per year with drainage and pain; a 30- propose to add a note directing raters to soiling that is not frequent enough or percent evaluation for three or more evaluate under diagnostic code 7350 extensive enough to require daily abscesses (each lasting less than a week) (colostomy or ileostomy), if an ostomy wearing of absorbent material. per year with drainage and pain ; and is present. In addition to proposing These criteria would promote more a 10-percent evaluation either for one or more objective criteria in order to consistent evaluations, and they provide two abscesses (each lasting less than a promote consistency of evaluations, we a range of evaluation levels consistent week) per year with drainage and pain, have proposed criteria that are generally with the range of severity of this or for a fistula with pain and discharge in agreement with our consultants’ condition. Our consultants but without associated abscesses. We suggestions, excluding the subjective recommended criteria based on propose to delete the zero-percent modifiers, such as ‘‘moderate’’ and frequency of prolapse, whether or not evaluation as unnecessary for clarity ‘‘occasional,’’ that they used. These there is incontinence, difficult (see § 4.31). These evaluation criteria are criteria are also internally consistent evacuation, and soiling. However, they better suited and more appropriate for with the proposed criteria for evaluating used numerous subjective terms, such evaluating this disability because, in impaired control of the anal sphincter. as ‘‘mild,’’ ‘‘moderate,’’ ‘‘severe,’’ addition to being more objective, they ‘‘frequently,’’ and ‘‘occasional,’’ and our Prolapse of Rectum (Diagnostic Code are based on the usual disabling effects proposed criteria represent a 7334) of fistula in ano. They represent modification of their recommendations modifications of the suggestions made Diagnostic code 7334, ‘‘rectum, for the sake of objectivity and internal by our consultants, faithful in prolapse of,’’ currently has evaluation consistency with other digestive substance, but with some changes made levels of 50, 30, and 10 percent. A 50- condition evaluations. partly for the sake of internal percent evaluation is assigned if there is Our consultants also recommended consistency and partly to remove ‘‘severe (or complete), persistent’’ rectal that solitary rectal ulcer syndrome be subjective terms. prolapse. A 30-percent evaluation is included in this code. However, in our Our consultants suggested we add a assigned if there is ‘‘moderate, experience, this condition occurs too diagnostic code for the evaluation of persistent or frequently recurring’’ rectal infrequently to warrant inclusion, and other defecation disorders, such as prolapse, and a 10-percent evaluation is in addition, the symptoms of solitary Hirschprung’s disease (congenital assigned if there is mild , rectal ulcer syndrome—altered bowel megacolon), (paradoxical ‘‘with constant slight or occasional habits with blood and mucous in the pelvic muscle contraction), levator moderate leakage.’’ These criteria stool, anorectal pain, a feeling of spasm syndrome, functional require raters to subjectively determine incomplete evacuation, and straining at constipation, and outlet obstruction. We whether the condition is ‘‘mild,’’ defecation (Yamada, 1824)—are not do not propose to do so because these ‘‘moderate,’’ or ‘‘severe,’’ and what level entirely consistent with the condition- conditions are either uncommon in our of frequency the term ‘‘frequently specific criteria we are proposing for experience, congenital in origin and recurring’’ implies. rectal prolapse. If solitary rectal ulcer likely to disqualify for military service, Our consultants noted that syndrome requires evaluation, it may be or have no organic basis. Any condition incontinence is the major problem rated as an analogous condition under that requires evaluation for associated with prolapse of the rectum the evaluation criteria for prolapse of compensation purposes can be and that higher evaluation levels should the rectum or other digestive condition evaluated under existing codes as an be available for this condition. We in the rating schedule, depending on the analogous condition. therefore propose to provide levels of particular signs and symptoms found. 100, 60, 30, and 10 percent, as we are Hemorrhoids (Diagnostic Code 7336) proposing for diagnostic codes 7332 and Fistula in Ano (Diagnostic Code 7335) Hemorrhoids, external or internal, 7333, the codes for other conditions that Fistula in ano, diagnostic code 7335, (diagnostic code 7336) are currently are also characterized primarily by fecal is currently evaluated as impairment of evaluated at 20, 10, or zero percent. A incontinence. We propose to remove the sphincter control, diagnostic code 7332. 20-percent evaluation is provided for subjective language and base evaluation The current evaluation criteria for ‘‘persistent bleeding and with secondary on more objective criteria, such as the impairment of sphincter control are not anemia, or for fissures;’’ a 10-percent frequency of prolapse, the presence of ideal for evaluating fistula in ano, evaluation for hemorrhoids that are incontinence, and the extent of fecal however, because they do not take into ‘‘large or thrombotic, irreducible, with soiling. account abscesses with pain and excessive redundant tissue, evidencing We propose a 100-percent evaluation drainage, which our consultants pointed frequent recurrences;’’ and a zero- for persistent prolapse with complete out are the primary disabling effects of percent evaluation if they are ‘‘mild or inability to control liquid or solid feces; fistulas. We therefore propose to moderate.’’ According to our a 60-percent evaluation for intermittent provide a specific set of evaluation consultants, external hemorrhoids are prolapse (occurring three or more times criteria based on these effects, with seldom chronically disabling, but can weekly) with complete inability to evaluation levels of 100, 60, 30, and 10 cause intermittent problems when they control liquid or solid feces during percent, the same levels as for other anal undergo thrombosis. Internal periods of prolapse; a 30-percent disabilities. hemorrhoids may undergo frequent or evaluation for intermittent prolapse Fistula in ano may also be called permanent prolapse, thrombosis, and (occurring three or more times weekly) anorectal fistula or , bleeding sufficient to cause anemia. The

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current evaluation criteria under hernia defect (first introduced in 1962 greatest diameter that is less than 15 diagnostic code 7336 do not (http://www.ednf.org/medical/content/ centimeters; and a 10-percent evaluation differentiate between internal and view/321/38/, Ehlers-Danlos National for a hernia with all of the following: is external hemorrhoids. Foundation, 2006)) and surgical repair of any size, can be corrected by surgery, We propose to change the title of performed by (first requires support and is supportable by diagnostic code 7336 from described in 1990 (http:// external devices, and is easily reducible. ‘‘hemorrhoids, external or internal’’ to www.rcsed.ac.uk/Journal/vol45_1/ We do not propose to retain a zero- ‘‘hemorrhoids,’’ because the single term 4510006.htm, P. Ridings and D.S. Evans, percent level as it is not needed for encompasses all types of hemorrhoids, J.R.Coll.Surg.Edinb., 45; 1: 29–32, clarity (see § 4.31). and to provide criteria that apply in part February 2000)). Therefore, we do not In addition to being more objective, to any type of hemorrhoids and in part propose to include the fact that a hernia these criteria provide sharper only to either internal or external is or is not recurrent in the evaluation distinctions between the levels of hemorrhoids. We propose to retain criteria. Recurrent (or initial) disability. There is currently a note evaluation levels of 20 and 10 percent, that cannot be repaired are under this diagnostic code directing but to remove the zero-percent encompassed by the evaluation criterion raters to add 10 percent for bilateral evaluation criteria as unnecessary (see of ‘‘cannot be corrected by surgery’’ in involvement, provided the second § 4.31). We also propose to remove proposed diagnostic code 7338 at the hernia is compensable, and explaining subjective terms such as ‘‘mild,’’ 60- and 30-percent evaluation levels, that this means that the more severely ‘‘moderate,’’ ‘‘excessive,’’ and and complications resulting from the disabling hernia is to be evaluated, and ‘‘frequent’’ that are in the current repair of any hernia can be evaluated 10 percent only is to be added for the criteria and replace them with more separately. second hernia, if the latter is of objective criteria. We propose a 20- The current evaluation levels are 60, compensable degree. In our judgment, percent evaluation for either of the 30, 10, and zero percent, and we two hernias, each of which meets the following: Persistent bleeding with propose to retain all but the zero- criteria for a 60-percent evaluation, for anemia, or permanently prolapsed percent level. A 60-percent evaluation is example, would be more disabling in internal hemorrhoids with three or more now assigned for a hernia that is ‘‘large, combination than two hernias, one of episodes per year of thrombosis. We postoperative, recurrent, not well which meets the criteria for a 60-percent propose a 10-percent evaluation for supported under ordinary conditions evaluation, and the other for a 10- either permanently or intermittently and not readily reducible, when percent evaluation, although under prolapsed internal hemorrhoids with considered inoperable;’’ a 30-percent current regulations they would be one or two episodes per year of evaluation for a hernia that is ‘‘small, evaluated the same. We therefore thrombosis, or for external hemorrhoids postoperative recurrent, or unoperated propose to remove this note, and to with three or more episodes per year of irremediable, not well supported by replace it with a note directing that each thrombosis. These criteria would truss, or not readily reducible;’’ a 10- hernia be separately evaluated and the provide raters with a clear, objective percent evaluation for a hernia that is evaluations combined (under the way to evaluate any type of ‘‘postoperative recurrent, readily provisions of § 4.25). hemorrhoids, while taking into account reducible and well supported by truss or Our consultants suggested evaluation the differences in the disabling effects of belt;’’ and a zero-percent evaluation levels for inguinal and femoral hernias external and internal hemorrhoids. both for a hernia that is ‘‘not operated, of 80 10, and zero percent. We do not but remediable’’ and for one that is believe that this sequence of evaluation Hernia, Inguinal or Femoral (Diagnostic ‘‘small, reducible, or without true hernia levels would allow adequate assessment Code 7338) protrusion.’’ of the potential disabling effects of , diagnostic code 7338, We propose to remove the subjective femoral and inguinal hernias because of and , diagnostic code terms and provide more objective the very large gap between the 80- and 7340, have similar disabling effects and criteria, for example, replacing ‘‘large’’ 10-percent evaluation levels. In our are currently rated under the same and ‘‘small’’ with the actual greatest judgment, some hernias would fall into criteria. There is no statistical need for diameter of the hernia, in order to a level of severity between these levels. VA purposes to retain separate remove ambiguity. Since both femoral In addition, based on our experience, diagnostic codes for each type of hernia, and inguinal hernias may or may not be including an 80-percent level is not and we therefore propose to combine correctable by surgery (although not warranted because there are very few them under diagnostic code 7338, and being correctable is less common with veterans with hernias that are currently retitle that diagnostic code ‘‘Hernia, modern surgical and anesthetic evaluated at a level higher than 30 inguinal or femoral (both post-operative techniques), may or may not be percent. It is very unlikely that recurrent and non-operated).’’ We supportable by external devices, and evaluations as high as 80 percent would propose to delete diagnostic code 7340. may or may not be easily reducible, be appropriate or necessary. For the The issue of whether or not a hernia had regardless of whether or not they have exceptional case that might present a been previously repaired is part of the been operated, we propose to picture of disability more severe than is current evaluation criteria, but we are differentiate the criteria for 60- and 30- warranted under the proposed 60- proposing criteria that would apply to percent evaluations only on the basis of percent upper limit of evaluation, 38 both initial and recurrent hernias the size of the hernia. We propose a 60- CFR 3.321(b)(1), which provides for because the potential signs and percent evaluation for a hernia with all extra-schedular evaluations in cases symptoms are the same. At the time the of the following: greatest diameter is 15 where an evaluation is inadequate current evaluation criteria were centimeters (5.91 inches) or more, because the condition presents such an developed, the repair of recurrent cannot be corrected by surgery, and unusual disability picture that applying hernias, which is more difficult than the requires support but is not well the regular schedular standards would repair of initial hernias, was not as supported by external devices or is not be impractical, provides a way to assign reliable or effective as it is with modern easily reducible; a 30-percent evaluation a higher evaluation. The consultants’ surgical techniques for , for a hernia with the same findings as suggested evaluation criteria also such as the use of mesh to cover a for a 60-percent evaluation except for a included subjective language such as

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‘‘moderate,’’ ‘‘mild,’’ and ‘‘small,’’ and propose to base evaluation in part on percent evaluation for the same criteria they retained the references to recurrent size, but also in part on whether or not as for a 60-percent evaluation except hernia. We have already explained why the hernia is externally supportable. The that it applies to a ventral hernia with we are not basing evaluation on whether presence of pain or incarceration (being greatest diameter less than 20 or not a hernia is recurrent. In addition, irreducible) is also relevant to the extent centimeters (7.87 inches), and a 10- they suggested using pain as one of the of disability, according to our percent evaluation for a ventral hernia criteria, but, in our judgment, the more consultants. However, as discussed of any size that requires support, and is objective criteria we are proposing above under inguinal and femoral supportable by external devices, and would take pain, a subjective symptom, hernias, we consider pain to be that is easily reducible. We also propose into account as part of the effects of a included as part of the effects of other to delete the zero-percent level, with hernia (for example, as part of whether criteria we are proposing to use. current criteria of postoperative wounds or not a hernia is supportable or We propose evaluation levels of 100, that are healed, with no disability, and reducible, and its size), and the more 60, 30, and 10 percent for ventral a belt not indicated, since those criteria objective criteria would promote hernia, instead of the current levels of all indicate the absence of any disability accurate and more consistent 100, 40, 20, and zero percent. These and are not necessary for evaluation. evaluations. For these reasons, we do levels would provide a range of Visceroptosis not propose to adopt our consultants’ evaluations appropriate to ventral suggestions for the evaluation of hernias, and allow a clear distinction Our consultants noted that the term hernias. between the levels, while eliminating ‘‘visceroptosis,’’ the title of current the large gap between 100 and 40 diagnostic code 7342, is obsolete. This Ventral Hernia, Postoperative percent. In our opinion, some hernias term was used to describe variations in (Diagnostic Code 7339) would fall into the area between 100 positions of the organs in the body, Diagnostic code 7339 is currently and 40 percent levels of severity. The which medical practitioners once titled ‘‘Hernia, ventral, postoperative.’’ evaluation levels are also comparable to considered to be significant. The We propose to retitle this diagnostic the proposed levels for inguinal and differing positions of the organs are code as ‘‘Ventral (incisional) hernia, and femoral hernia under diagnostic code currently viewed as normal anatomical other abdominal hernias postoperative.’’ 7338. variations that are of no pathological ‘‘Incisional’’ is another term for ventral We propose to revise the criteria to significance. We therefore propose to hernia, and other incisional hernias that make them less ambiguous and clearer delete diagnostic code 7342 from the might not be ventral (flank incisions, for for more ease of use and consistency of schedule. example), would also be most evaluations. For example, we propose to Gastroesophageal Reflux Disease appropriately evaluated under this provide an evaluation of 100 percent for (Diagnostic Code 7346) diagnostic code. Ventral hernia is a hernia with a diameter of 30 or more currently evaluated at levels of 100, 40, centimeters, rather than employing the is currently evaluated 20, and zero percent. A 100-percent term ‘‘massive’’. In our judgment, a under diagnostic code 7346. According evaluation is assigned if a ventral hernia ventral hernia with a diameter of 30 to our consultants, the most disabling is massive, persistent, and there is centimeters (11.81 inches) or greater is manifestation of hiatal hernia is severe diastasis of recti muscles or a hernia of such size that it would be gastroesophageal reflux. To reflect this extensive diffuse destruction or totally disabling if it cannot be repaired fact, we propose to change the title of weakening of muscular and fascial because of loss of tissue support. We diagnostic code 7346 from ‘‘hernia support of the abdominal wall so as to also propose to remove the reference to hiatal’’ to ‘‘gastroesophageal reflux be inoperable; a 40-percent evaluation if diastasis of recti muscles because our disease (GERD), hiatal hernia, a hernia is large and not well supported consultants pointed out that diastasis esophagitis, lower esophageal by a belt under ordinary conditions; a recti is a congenital condition of the (Schatzki’s) ring.’’ These conditions are 20-percent evaluation if a hernia is abdominal wall that is not necessarily closely related, and their symptoms small and not well supported by a belt accompanied by a hernia. We further overlap, so evaluating them under the under ordinary conditions, or if there is propose to substitute ‘‘refractory to same criteria is appropriate and would a healed ventral hernia or postoperative further operative correction due to promote more consistent evaluations. wounds with weakening of the extensive loss of muscular and fascial The current evaluation levels are 60, 30, abdominal wall and there is an support’’ in lieu of considered and 10 percent. We propose to retain indication for a supporting belt; and a ‘‘inoperable’’ to indicate that it must be these levels, and to add a zero-percent zero-percent evaluation if there are the status of the hernia itself, rather than level for the sake of clarity. The current postoperative wounds that are healed, unrelated medical reasons, that makes criteria under diagnostic code 7346 call with no disability, and a belt is not the hernia unsuitable for surgical for a 60-percent evaluation if there are indicated. These criteria contain the correction. ‘‘symptoms of pain, vomiting, material indefinite terms ‘‘massive,’’ ‘‘large,’’ and We therefore propose a 100-percent weight loss[,] and hematemesis or ‘‘small,’’ which could be interpreted evaluation for a ventral hernia with both melena with moderate anemia, or other differently by different people. of the following: greatest diameter is 30 symptom combinations productive of According to our consultants, whether centimeters (11.81 inches) or more and severe impairment of health;’’ a 30- or not a ventral hernia is supportable is is refractory to further operative percent evaluation if there is more useful than size, which is correction due to extensive loss of persistently ‘‘recurrent epigastric currently used to distinguish between muscular and fascial support. We distress with dysphagia, pyrosis, and the 20- and 40-percent levels of propose a 60-percent evaluation for a regurgitation, accompanied by disability. However, both to distinguish ventral hernia with both of the substernal or arm or shoulder pain, more clearly the levels of evaluation, following: greatest diameter is 20 productive of considerable impairment and because, in our judgment, a large centimeters (7.87 inches) or more and of health;’’ and a 10-percent evaluation hernia that is not supportable is likely requires support but is not well if there are two or more of the same to interfere with activities more than a supported by external devices or is not symptoms as for the 30-percent small non-supportable hernia, we easily reducible. We propose a 30- evaluation, but of less severity.

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These criteria rely on subjective ‘‘moderate,’’ and ‘‘severe’’ with more , if symptomatic and interpretations of terms such as objective criteria. requiring continuous treatment with ‘‘severe’’ or ‘‘considerable’’ impairment We also propose to add a note prescription medication; or minimum of health, symptoms of ‘‘less severity,’’ directing that raters evaluate esophageal evaluation following total and ‘‘persistently recurrent’’ symptoms stricture, which may result from pancreatectomy. We propose a 10- and could lead to different esophagitis, under the General Rating percent evaluation for one or two interpretations by different individuals. Formula for Residuals of mouth injuries documented attacks of pancreatitis per We propose to remove the indefinite (7200), Residuals of lip injuries (7201), year, and a zero-percent evaluation for language and base evaluation on more Residuals of tongue injuries, including partial pancreatectomy, if asymptomatic objective criteria that are also more tongue loss (7202), Esophageal stricture and not requiring continuous treatment inclusive of the effects of this group of (7203), Achalasia (cardiospasm) and with prescription medication. We are conditions than the current evaluation other motor disorders of the esophagus proposing to add the zero-percent criteria. The proposed criteria would be (7204), and Esophageal diverticula evaluation level for asymptomatic (7205). based on such signs and symptoms as partial pancreatectomy, since it might the presence of erosive reflux Pancreatitis, Total Pancreatectomy, and not be clear to raters what the evaluation would be in this case, and as esophagitis, anemia, hemorrhage, Partial Pancreatectomy (Diagnostic Code 7347) recommended by our consultants. weight loss, and pulmonary aspiration, Total pancreatectomy is disabling in and of certain symptoms such as Diagnostic code 7347, pancreatitis, is that it requires the administration of pyrosis, retrosternal or arm or shoulder currently evaluated at levels of 100, 60, pancreatic enzymes and insulin pain, dysphagia, and odynophagia. 30, or 10 percent. The criteria call for a (‘‘Textbook of Surgery’’ 1096 (David C. We propose a 60-percent evaluation 100-percent evaluation if there are Sabiston, Jr., M.D., ed., 14th ed. 1991)), for erosive reflux esophagitis frequently recurrent disabling attacks of but, according to our consultants, a (inflammation and ulceration of the abdominal pain with few pain free partial pancreatectomy without residual esophagus due to reflux of gastric intermissions and with steatorrhea, symptoms and not requiring ongoing contents into the esophagus) confirmed malabsorption, diarrhea and severe medical treatment is not disabling. by endoscopy, imaging, or other malnutrition; a 60-percent evaluation if These criteria are generally in accord laboratory procedure, with at least one there are frequent attacks of abdominal with the suggestions of our consultants of the following: anemia and substantial pain, loss of normal body weight, and and are more objective and measurable weight loss, one or more episodes per other findings showing continuous than the current criteria. They would, year of gastrointestinal hemorrhage, or pancreatic insufficiency between acute therefore, promote consistent two or more episodes per year of attacks; a 30-percent evaluation if the evaluations. pulmonary aspiration (with bronchitis, condition is moderately severe, with at Including information about pneumonia, or pulmonary abscess) due least 4–7 typical attacks of abdominal pancreatectomy in the criteria pain per year with good remission to regurgitation. We propose a 30- themselves makes the current note on between attacks; and a 10-percent percent evaluation for confirmed erosive that subject (note two under current evaluation if there is at least one reflux esophagitis, with symptoms such diagnostic code 7347) unnecessary, and recurring attack of typical severe as pyrosis (heartburn), retrosternal or we propose to delete it. Current note abdominal pain in the past year. We arm or shoulder pain, regurgitation of one under diagnostic code 7347 states, propose to evaluate pancreatitis on the ‘‘Abdominal pain in this condition must gastric contents into the mouth, basis of similar criteria, but to remove be confirmed as resulting from dysphagia (difficulty swallowing), and the indefinite adjectives ‘‘frequent,’’ pancreatitis by appropriate laboratory odynophagia (pain during swallowing) ‘‘severe,’’ and ‘‘moderately severe’’ in and clinical studies.’’ We propose to that are intractable despite treatment, or favor of more objective criteria. retain that note, but to edit it, and to add with one episode per year of pulmonary We propose a 100-percent evaluation a paragraph describing the signs and aspiration (with bronchitis, pneumonia, if all of the following are present: daily symptoms of an attack of pancreatitis. or pulmonary abscess) due to or near-daily debilitating attacks of Note one would say that for purposes of regurgitation. We propose a 10-percent pancreatitis (to be defined in a note) evaluation under diagnostic code 7347, evaluation for the same symptoms as for with few pain-free intermissions; two or an attack of pancreatitis means the 30-percent level, but that are largely more signs of pancreatic insufficiency abdominal pain, often very severe, and controlled by continuous treatment with (such as steatorrhea, , sometimes radiating through to the prescription medication; and a zero- malabsorption, diarrhea, and back, with any combination of nausea, percent evaluation for the same malnutrition); and unresponsive to vomiting, anorexia (lack or loss of symptoms, but that are intermittent and medical treatment. We propose a 60- appetite), fever, and abdominal that respond to dietary changes, lifestyle percent evaluation if the following is tenderness and swelling. (Merck, 1129 changes, or treatment with antacids or present: seven or more documented and http://digestive.niddk.nih.gov/ other nonprescription medications. In attacks of pancreatitis per year with at ddiseases/pubs/pancreatitis/ this case, we are proposing a zero- least one sign of pancreatic index.htm#acute, National Digestive percent level because the criteria that insufficiency (such as steatorrhea, Diseases Information Clearinghouse, are provided list items such as lifestyle diabetes, malabsorption, diarrhea, or February 2004). These symptoms must and dietary changes that are not malnutrition) between acute attacks. We be confirmed as resulting from otherwise addressed in the criteria but propose a 30-percent evaluation if any pancreatitis by appropriate laboratory that are used to treat these conditions, of the following is present: three to six and clinical studies. and it might be unclear to raters documented attacks of pancreatitis per We propose to add a second note whether they warrant a zero- or a 10- year with at least one sign of pancreatic directing raters to evaluate percent evaluation. These criteria are in insufficiency (such as steatorrhea, complications, such as diabetes general agreement with the suggestions diabetes, malabsorption, diarrhea, or mellitus, external gastrointestinal of our consultants, but with replacement malnutrition) between acute attacks; fistula, and malabsorption, separately of subjective language such as ‘‘mild,’’ minimum evaluation following partial under an appropriate diagnostic code, as

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long as the same findings are not used conditions not listed in the rating diagnostic code 7333, stricture of the to support more than one evaluation. schedule can be evaluated under rectum and anus, where a 100-percent analogous codes. evaluation is assigned if a colostomy is Pyloroplasty With Vagotomy or required for that condition. Since a With Vagotomy Proposed Conditions To Be Added colostomy (an opening on the (Diagnostic Code 7348) We do propose to add four commonly abdominal wall from the colon) may be Vagotomy with pyloroplasty or occurring digestive conditions to the required for many conditions, however, gastroenterostomy, diagnostic code rating schedule: Bowel stricture, as and is a common finding, we propose to 7348, is currently evaluated at 40, 30 or diagnostic code 7349, colostomy or establish a separate code, diagnostic 20 percent. A 40-percent evaluation is ileostomy, as diagnostic code 7350, code 7350, for the evaluation of either assigned if there are demonstrably pancreatic transplant, as diagnostic code colostomy or ileostomy (an opening on confirmative postoperative 7352, and malabsorption syndrome, as the abdominal wall from the ), a complications of stricture or continuing diagnostic code 7353, as described related and also common condition, gastric retention; a 30-percent below. with evaluation criteria specific to these evaluation if there are symptoms and a Bowel Stricture (Diagnostic Code 7349) disabilities. confirmed diagnosis of alkaline gastritis, Individuals vary in the extent of or of confirmed persisting diarrhea; and Currently, the only evaluation criteria disability they experience following a 20-percent evaluation if there is in the rating schedule for stricture of the ileostomy or colostomy. For example, recurrent ulcer with incomplete bowel are those provided under following ileostomy, patients generally vagotomy. There is also a note directing diagnostic code 7333, stricture of the return to an active physical life and raters to evaluate recurrent ulcer rectum and anus. We are proposing to resume their previous work, and following complete vagotomy under delete stricture of the rectum from restriction of their activities may vary diagnostic code 7305 (duodenal ulcer), diagnostic code 7333, as recommended from mild to severe (Yamada, 799). with a minimum evaluation of 20 by our consultants, and instead provide Many patients with a colostomy, and percent, and to rate dumping syndrome a new diagnostic code, diagnostic code some with an ileostomy, do not require under diagnostic code 7308 7349, ‘‘Bowel stricture,’’ for the a bag or appliance (Sabiston, 903; (postgastrectomy syndromes). We evaluation of stricture of the bowel at Yamada, 799). Some individuals, propose to direct that this condition be any level, including the rectum. This however, have persistent infection or evaluated as duodenal ulcer (diagnostic would remove the need to evaluate a other ostomy problems that may be very code 7305); gastritis (diagnostic code bowel stricture under an analogous disabling. We therefore propose to base 7307); postgastrectomy syndromes code. the evaluation on whether or not there (diagnostic code 7308); or gastric We propose to establish evaluation is an ostomy complication and on emptying disorders (diagnostic code levels of 60, 30, and 10 percent for whether or not the ostomy is continent. 7309), depending upon symptoms and bowel strictures. These levels are the We propose to provide evaluation findings, in order to provide a wide same as those we are proposing for levels of 100, 60, and 30 percent, in range of objective evaluation criteria peritoneal adhesions (Diagnostic Code order to provide a range of appropriate appropriate to the numerous signs and 7301), and the evaluation criteria are evaluation levels. We propose a 100- symptoms that may result from this also almost identical, because partial percent evaluation for at least one disability, and to assure more consistent bowel obstruction due to peritoneal ostomy complication (such as infection evaluations. This is in accord with adhesions results in similar signs and or signs of irritation of the peristomal recommendations by our consultants. symptoms as bowel stricture. We area, prolapse, retraction, or stenosis) With the directions for using this propose a 60-percent evaluation for six that is refractory to treatment; a 60- broader range of evaluation criteria, the or more episodes per year of partial percent evaluation for incontinence, note is not necessary, and we propose obstruction of the bowel (confirmed by requiring the use of an external to remove it. In addition, since the an imaging procedure), with typical appliance or absorbent material; and a major impairments from these signs and symptoms; a 30-percent 30-percent evaluation if the individual conditions are ordinarily due to the evaluation for three to five such is continent, with no external appliance gastric surgery, or to the combined episodes; and a 10-percent evaluation or absorbent material required. effects of gastric surgery and vagotomy, for one or two such episodes. As with Pancreas Transplant (Diagnostic Code rather than primarily due to the peritoneal adhesions, we are proposing 7352) vagotomy, we propose to change the to add a note to list the typical signs and title to ‘‘pyloroplasty with vagotomy or symptoms of bowel stricture. The note We propose to add pancreatic gastroenterostomy with vagotomy’’ to would state that they include colicky transplant as diagnostic code 7352, indicate this. abdominal pain and at least one of the because this surgical procedure has following other symptoms: Abdominal been developed since the current Consultant-Recommended Conditions distention, borborygmi (audible schedule went into effect and is done To Be Added rumbling bowel sounds), nausea, frequently enough to warrant inclusion. Our consultants suggested adding vomiting, and obstipation (severe We propose a 100-percent evaluation several conditions to the rating constipation). These proposed criteria following transplant surgery. We further schedule—gastrointestinal hemorrhage, are specific to the condition, are propose the addition of a note non-ulcerative dyspepsia, and porto- objective, and are similar to criteria we explaining the requirement of a VA systemic shunting. Our experience has are proposing to use to evaluate examination one year following hospital shown that these conditions do not peritoneal adhesions, as recommended discharge. We propose to provide occur commonly enough to warrant by our consultants. instructions to evaluate thereafter on inclusion. Furthermore, the first two are residuals, based on the VA examination, signs or symptoms rather than diseases Colostomy or Ileostomy (Diagnostic and subject to the provisions of 38 CFR or injuries, and they may not be Code 7350) 3.105(e). Any proposed reduction would appropriate in the schedule for that In the current rating schedule, be based on the examination, and the reason. When necessary, digestive colostomy is mentioned only under notification process could begin only

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after the examination had been Regulatory Flexibility Act governments, in the aggregate, or by the reviewed. This gives the claimant The Secretary hereby certifies that private sector, of $100 million or more current notice of any proposed action this proposed rule would not have a (adjusted annually for inflation) in any and the opportunity to present evidence significant economic impact on a given year. This proposed rule would showing that the proposed action substantial number of small entities as have no such effect on State, local, and tribal governments, or on the private should not be taken. We propose a they are defined in the Regulatory sector. minimum 30-percent evaluation for Flexibility Act, 5 U.S.C. 601–612. This pancreatic transplant, because of the proposed rule would not affect any Catalog of Federal Domestic Assistance need for long-term immunosuppressive small entities. Only VA beneficiaries Numbers and Titles medication and its associated problems. could be directly affected. Therefore, The Catalog of Federal Domestic The evaluation criteria we are proposing pursuant to 5 U.S.C. 605(b), this are the same as those used for kidney Assistance program numbers and titles proposed rule is exempt from the initial for this proposal are 64.104, Pension for transplant (diagnostic code 7531) in the and final regulatory flexibility analysis genitourinary section of the rating Non-Service-Connected Disability for requirements of sections 603 and 604. Veterans, and 64.109, Veterans schedule, because both types of Compensation for Service-Connected transplant require similar periods of Executive Order 12866 Disability. convalescence and long-term Executive Order 12866 directs immunosuppressive therapy following agencies to assess all costs and benefits Signing Authority convalescence. of available regulatory alternatives and, The Secretary of Veterans Affairs, or when regulation is necessary, to select Malabsorption Syndrome (Diagnostic designee, approved this document and regulatory approaches that maximize Code 7353) authorized the undersigned to sign and net benefits (including potential submit the document to the Office of the Malabsorption syndrome (including economic, environmental, public health Federal Register for publication celiac disease, small bowel bacterial and safety, and other advantages; electronically as an official document of overgrowth, Whipple’s disease distributive impacts; and equity). The the Department of Veterans Affairs. John (intestinal lipodystrophy), and fistulous Executive Order classifies a ‘‘significant R. Gingrich, Chief of Staff, Department disorders) is a common syndrome that regulatory action,’’ requiring review by of Veterans Affairs, approved this can result from a number of conditions the Office of Management and Budget document on March 31, 2011, for and result in significant impairment, (OMB), unless OMB waives such publication. review, as any regulatory action that is and we propose to add it as diagnostic List of Subjects in 38 CFR Part 4 code 7353, with evaluation levels of likely to result in a rule that may: (1) 100, 60, 30, and 10 percent. We propose Have an annual effect on the economy Disability benefits, Pensions, a 100-percent evaluation if total of $100 million or more or adversely Veterans. parenteral (intravenous or affect in a material way the economy, a Dated: June 20, 2011. intramuscular) nutritional support is sector of the economy, productivity, William F. Russo, required; a 60-percent evaluation for competition, jobs, the environment, Deputy Director, Office of Regulation Policy diarrhea, anemia, weakness, and fatigue public health or safety, or State, local, & Management, Department of Veterans requiring daily (oral) nutritional or tribal governments or communities; Affairs. supplementation, plus parenteral (2) create a serious inconsistency or For the reasons set forth in the (intravenous or intramuscular) nutrition otherwise interfere with an action taken preamble, VA proposes to amend 38 for a total of at least 28 days per year; or planned by another agency; (3) CFR part 4, subpart B, as set forth a 30-percent evaluation for diarrhea, materially alter the budgetary impact of below: weakness, and fatigue requiring daily entitlements, grants, user fees, or loan (oral) nutritional supplementation, plus programs or the rights and obligations of PART 4—SCHEDULE FOR RATING parenteral (intravenous or recipients thereof; or (4) raise novel DISABILITIES intramuscular) nutrition for a total of at legal or policy issues arising out of legal mandates, the President’s priorities, or 1. The authority citation for part 4 least 14 days, but less than 28 days per continues to read as follows: year; and a 10-percent evaluation for the principles set forth in the Executive Order. Authority: 38 U.S.C. 1155, unless diarrhea, weakness, and fatigue The economic, interagency, otherwise noted. requiring daily (oral) nutritional budgetary, legal, and policy supplementation. These are similar to 2. Revise § 4.110 to read as follows: implications of this proposed rule has the criteria proposed for small bowel been examined and it has been § 4.110 Dyspepsia. resection (diagnostic code 7328) because determined to be a significant regulatory For purposes of evaluating conditions the effects are similar. Our consultants action under Executive Order 12866 in § 4.114, ‘‘dyspepsia’’ means any recommended that the diagnosis of because it is likely to result in a rule that combination of the following symptoms: malabsorption syndrome be confirmed may raise novel legal or policy issues Gnawing or burning epigastric or based on a fecal fat loss of 17mEq or arising out of legal mandates, the substernal pain that may be relieved by greater per day. However, this is not the President’s priorities, or the principles food (especially milk) or antacids, primary diagnostic test for every type of set forth in the Executive Order. nausea, vomiting, anorexia (lack or loss malabsorption syndrome, and we do not of appetite), abdominal bloating, and propose to require it. Unfunded Mandates belching. When there is obstruction of Paperwork Reduction Act The Unfunded Mandates Reform Act the outlet of the stomach (gastric outlet of 1995 requires, at 2 U.S.C. 1532, that obstruction), dyspepsia may also This document contains no provisions agencies prepare an assessment of include symptoms of gastroesophageal constituting a collection of information anticipated costs and benefits before reflux (flow of stomach contents back under the Paperwork Reduction Act (44 issuing any rule that may result in an into the esophagus), borborygmi U.S.C. 3501–3521). expenditure by State, local, and tribal (audible rumbling bowel sounds),

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crampy pain, and obstipation (severe nutrients. It is characterized by failure 6. Amend § 4.114 by: constipation). of the body to maintain normal organ a. Removing the introductory text. functions and healthy tissues. b. Removing diagnostic codes 7315, § 4.110 [Removed and Reserved] 5. Revise § 4.113 to read as follows: 7316, 7317, 7318, 7321, 7322, 7337, 3. Remove and reserve § 4.111. § 4.113 Evaluation of coexisting digestive 7340, and 7342. 4. In § 4.112, revise the section conditions. c. Revising diagnostic codes 7200 heading and add two sentences at the Separately evaluate two or more through 7310, 7314 through 7339, and end of the paragraph to read as follows: conditions in § 4.114 only if the signs 7346 through 7348. and symptoms attributed to each are § 4.112 Weight loss and malnutrition. d. Adding diagnostic codes 7207, separable. If they are not, assign a single 7349, 7350, 7352, and 7353. * * * ‘‘Malnutrition’’ means a evaluation under the diagnostic code The revisions and additions read as deficiency state resulting from that best allows evaluation of the overall follows: insufficient intake of one or multiple functional impairment resulting from essential nutrients or the inability of the both conditions. § 4.114 Schedule of ratings—Digestive body to absorb, utilize, or retain such Authority: (38 U.S.C. 1155) 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, nut- cracker 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 vom- iting; 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 symp- toms: 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 § 4.25.. 7207 Salivary gland (parotid, submandibular, sublingual) disease other than neoplasm: 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 ...... 20 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.

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Rating

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 the bowel (confirmed by X-ray), with typical signs and symptoms ...... 60 Three to five episodes per year of partial obstruction of the bowel (confirmed by X-ray), with typical signs and symptoms ...... 30 One or two episodes per year of partial obstruction of 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 ...... 10 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 in- clude colicky abdominal pain, and at least one of the following other symptoms: abdominal distention, borborygmi (audible rum- bling 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, ob- struction, 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 with prescription medication for control ...... 10 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 gas- tritis): 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 prescription medication ...... 10 Note (1): Evaluation under diagnostic code 7307 requires that the diagnosis of chronic gastritis be confirmed on at least one occa- sion by endoscopy. Note (2): Evaluate atrophic gastritis, which is a complication of a number of diseases, including pernicious anemia, as part of the un- derlying condition. 7308 Postgastrectomy syndromes: Dumping syndrome that occurs after most meals, with substantial weight loss, malnutrition, and anemia ...... 100 Dumping syndrome that occurs after most meals, with substantial weight loss and anemia ...... 60 Dumping syndrome occurring daily or nearly so, despite treatment, with at least minor weight loss ...... 30 Intermittent dumping syndrome (occurring at least three times a week) requiring dietary restrictions ...... 10 Note (1): For purposes of evaluation under diagnostic code 7308, the term ‘‘dumping syndrome’’ includes symptoms that are associ- ated 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), diar- rhea, 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 disturb- ances): Daily or near-daily signs and symptoms with substantial weight loss and malnutrition ...... 100 Periodic or daily or near-daily signs and symptoms with substantial weight loss ...... 60 Periodic signs and symptoms with minor weight loss ...... 30 Periodic signs and symptoms, without weight loss, but requiring continuous treatment with prescription medication ...... 10 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:

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Evaluate as peritoneal adhesions (diagnostic code 7301), or, if the injury required a gastric resection, as postgastrectomy syn- dromes (diagnostic code 7308).

******* 7314 Biliary tract disease or injury (chronic cholecystitis, cholelithiasis, choledocholithiasis, chronic cholangitis, status post-chole- cystectomy, gall bladder or bile duct injury, , cholesterolosis, polyps of gall bladder, sclerosing cholangitis, stric- ture 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), nau- sea, 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 § 4.25) with an evaluation under diagnostic code 7314, as long as the same findings are not used to support more than one eval- uation (see § 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 (diarrhea, or alternating diarrhea and constipation), bloating, and abdominal cramping or pain, refractory to medical treatment ...... 30 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 ...... 10 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 in- tense) 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 in- tense) 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 ap- propriate 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 § 4.25, as long as the same findings are not used to support more than one evaluation (see § 4.14). 7324 Parasitic infections of the intestinal tract: Daily diarrhea (occurring more than three times per day) and abdominal pain, with at least minor weight loss ...... 30 Diarrhea and abdominal pain requiring continuous treatment with prescription medication for control ...... 10 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, refractory to medical treatment, and with three or more episodes per year of fluid and electrolyte imbalance requiring parenteral (intravenous or intramuscular) hydration ...... 60 Five or more watery bowel movements occurring daily, partially responsive to medical treatment, and with one or two episodes per year of fluid and electrolyte imbalance requiring parenteral (intravenous or intramuscular) hydration ...... 30 Requiring continuous treatment with prescription medication for control ...... 10 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

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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 § 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 § 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 (con- stipation, 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 abdominal pain and tenderness, fever, and irregular defecation (constipa- tion, diarrhea, or alternating constipation and diarrhea), requiring a course of antibiotics ...... 10 Note: Evaluate under diagnostic code 7350 (colostomy or ileostomy) if an ostomy is present, and under diagnostic code 7329 (re- section of large intestine), if applicable, as long as the same findings are not used to support more than one evaluation (see § 4.14). 7328 Resection of small intestine: Requiring total parenteral (intravenous or intramuscular) nutritional support ...... 100 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 ...... 60 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 ...... 30 Diarrhea, weakness, fatigue, abdominal cramps, and bloating requiring daily (oral) nutritional supplementation ...... 10 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 § 4.14). 7329 Resection of large intestine: 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 ...... 100 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 ...... 60 Four or more attacks of diarrhea and abdominal pain per year requiring medical treatment ...... 30 Two or three attacks of diarrhea and abdominal pain per year requiring medical treatment ...... 10 Note (1): Separately evaluate peritoneal adhesions (diagnostic code 7301), if applicable, and combine (under the provisions of § 4.25) with an evaluation under diagnostic code 7329, as long as the same findings are not used to support more than one eval- uation (see § 4.14). Note (2): Evaluate under diagnostic code 7350 (colostomy or ileostomy), if applicable, and combine (under the provisions of § 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 § 4.14). 7330 External gastrointestinal fistula (including biliary, pancreatic, esophageal, gastric, and intestinal fistulas): Constant or near-constant copious discharge that cannot be contained, and with any of the following ...... 100 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

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Two or more episodes per year of sepsis (a serious and sometimes life-threatening infection with a widespread inflammatory re- sponse). Constant or near-constant, copious discharge that cannot be contained, and with any of the following ...... 60 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 following ...... 30 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 following ...... 10 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 cri- teria for malabsorption (diagnostic code 7353) or other appropriate condition, depending on the particular findings. 7331 Tuberculous peritonitis: Active ...... 100 Inactive: Evaluate in accordance with §§ 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 liquid feces ...... 60 Fecal soiling that, although less than daily, is frequent enough or extensive enough to require daily wearing of absorbent mate- rial ...... 30 Fecal soiling that is intermittent, and not frequent enough or extensive enough to require daily wearing of absorbent material ..... 10 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 complete inability to control liquid or solid feces ...... 100 Reduction of the lumen by at least 50 percent, with pain and prolonged straining during defecation, and complete inability to control liquid feces ...... 60 Reduction of the lumen, but by less than 50 percent, with straining during defecation, and fecal incontinence that requires daily wearing of absorbent material ...... 30 Reduction of the lumen, with fecal soiling that is not frequent enough or extensive enough to require daily wearing of absorbent material ...... 10 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 liquid or solid feces ...... 100 Intermittent prolapse (occurring three or more times weekly): with complete inability to control liquid or solid feces during periods of prolapse ...... 60 Intermittent prolapse (occurring three or more times weekly): without complete inability to control liquid or solid feces during peri- ods 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 ...... 30 Intermittent prolapse with difficulty in bowel evacuation and fecal soiling that is not frequent enough or extensive enough to re- quire daily wearing of absorbent material ...... 10 7335 Fistula in ano (anorectal fistula, anorectal abscess): Constant or near-constant abscesses with drainage and pain, refractory to medical and surgical treatment ...... 100 Four or more abscesses (each lasting a week or more) per year with drainage and pain ...... 60 Three or more abscesses (each lasting less than a week) per year with drainage and pain ...... 30 One or two abscesses (each lasting less than a week) per year with drainage and pain, or; fistula with pain and discharge but without associated abscesses ...... 10 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 § 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.

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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 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 ...... 60 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 regurgita- tion. 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 either of the following ...... 30 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 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 ...... 10 Intermittent 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 respond to dietary changes, lifestyle changes, or treatment with antacids or other nonprescription medications ...... 0 Note: Evaluate esophageal strictures under the General Rating Formula for Residuals of mouth injuries (7200), Residuals of lip inju- ries (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 medi- cation; or Minimum evaluation following total pancreatectomy. One or two documented attacks of pancreatitis per year ...... 10 Partial pancreatectomy, if asymptomatic and not requiring continuous treatment with prescription medication ...... 0 Note (1): For purposes of evaluation under diagnostic code 7347, an attack of pancreatitis means abdominal pain, often very se- vere, 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 appro- priate 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 § 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 the bowel (confirmed by an imaging procedure), with typical signs and symptoms ...... 60 Three to five episodes per year of partial obstruction of the bowel (confirmed by an imaging procedure), with typical signs and symptoms ...... 30 One or two episodes per year of partial obstruction of the bowel (confirmed by an imaging procedure), with typical signs and symptoms ...... 10 Note: For purposes of evaluation under diagnostic code 7349, typical signs and symptoms of bowel stricture include colicky abdom- inal 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 or signs of irritation of the peristomal area, prolapse, retraction, or ste- nosis) that is refractory to treatment ...... 100 Incontinent, requiring the use of an external appliance or absorbent material ...... 60 Continent, not requiring external appliance or absorbent material ...... 30

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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 § 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) nutritional support ...... 100 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 ...... 60 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 ...... 30 Diarrhea, weakness, and fatigue requiring daily (oral) nutritional supplementation ...... 10

*******

[FR Doc. 2011–15698 Filed 7–1–11; 8:45 am] BILLING CODE 8320–01–P

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