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The Digestive System; Proposed Rule

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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 VerDate Mar<15>2010 19:36 Jul 01, 2011 Jkt 223001 PO 00000 Frm 00001 Fmt 4717 Sfmt 4717 E:\FR\FM\05JYP2.SGM 05JYP2 mstockstill on DSK4VPTVN1PROD with PROPOSALS2 39160 Federal Register / Vol. 76, No. 128 / Tuesday, July 5, 2011 / Proposed Rules 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 (esophagus, 38 CFR Part 4 reflect recent medical advances. diverticulum of, acquired), 7306 RIN 2900–AN12 Comments in Response To Advance (marginal ulcer), 7309 (stomach, 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 (visceroptosis) 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 disease; 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); hepatitis A, B, and visceroptosis is an obsolete diagnosis, as Disabilities that addresses the Digestive C; chronic inflammation of the liver and discussed further below. However, we System. The purpose of this change is its residuals; and malabsorption due to propose to retain all of the other to incorporate medical advances that pancreatic disease. 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 diseases, 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 esophagitis with hiatal www.Regulations.gov; by mail or hand- address injuries, including combat hernia, with the criteria taking into delivery to the Director, Regulations wounds, 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, duodenitis, determining response to therapy, and to The Digestive System. Copies of and Crohn’s disease; provide a prepare for surgery. They are less useful, comments received will be available for diagnostic code for total gastrectomy; 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, cirrhosis; provide evaluation criteria for symptoms, the impact of the condition Room 1063B, between the hours of ileostomy and colostomy; 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 pancreatitis. 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 hemorrhoids. 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 (pruritus ani) 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 dumping syndrome 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. VerDate Mar<15>2010 19:36 Jul 01, 2011 Jkt 223001 PO 00000 Frm 00002 Fmt 4701 Sfmt 4702 E:\FR\FM\05JYP2.SGM 05JYP2 mstockstill on DSK4VPTVN1PROD with PROPOSALS2 Federal Register / Vol. 76, No. 128 / Tuesday, July 5, 2011 / Proposed Rules 39161 Outside Consultants rumbling bowel sounds), crampy pain, We propose to direct the rater to In addition to publishing an advance and obstipation (severe constipation). 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
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