Basic Rating Formula for Heart Conditions
FYI, New Heart Ratings Are in Effect
The new revised regulations for cardiovascular ratings are effective on November 14, 2021.
In essence, this removes ejection fraction as a part of the ratings and focuses on the MET (metabolic equivalent) testing. Also removed congestive heart failure.
As with most changes this goes forward. This means if you have a cardiac rating based on injection fraction or congestive heart failure, be very careful if you open up new claims as a review may result in a reduction.
Heart Conditions Rated on the Basic Rating System
A 100% rating is given for the following conditions while the condition is active and continues for the first three months following the end of treatment or hospitalization for the condition. After that, the conditions are rated based on the basic heart rating system.
– Code 7000: Valvular heart disease includes any disease, including rheumatic heart disease, that involves one or more valves of the heart. This condition must be diagnosed using an echocardiogram, Doppler echocardiogram, or cardic catheterization. Rheumatic heart disease usually develops many years after the initial infection which causes the condition. Because of this, it can be judged to have existed prior to service and thus is not ratable even if it was not diagnosed before entering the military. Medical findings of murmurs or valvular lesions early in your career could be enough to prove it did exist prior to service.
– Code 7001 Endocarditis is the inflammation of the lining of the heart chambers and valves. This condition must be diagnosed using an echocardiogram, Doppler echocardiogram, or cardiac catheterization.
– Code 7002: Pericarditis is the inflammation of the covering tissue surrounding the heart. This condition must be diagnosed using an echocardiogram, Doppler echocardiogram, or cardic catheterization.
– Code 7006: Myocardial infarction (or a “heart attack”) occurs when the blood flow to a part of the heart is blocked, thus causing damage to the heart muscle.
– Code 7017 Coronary bypass surgery is performed if there is a block in a coronary artery. The surgeon grafts veins or arteries from the aorta directly to the artery, thus bypassing the block. The three-month period for this condition begins the day of admission to the hospital for the procedure.
The following conditions are given a 100% rating for an “indefinite” period of time before they are rated on the basic heart rating system.
– Code 7011: Sustained ventricular arrhythmias are abnormal heart rhythms, most commonly too fast, that are located in the heart’s two lower chambers. These rhythms can come and go and are usually treated with medication or electric therapy. This condition receives the 100% rating the entire time it is being treated in the hospital or the entire time an implantable defibrillator is in place. If a pacemaker is implanted, then it is rated under code 7018
– Code 7016: A heart valve replacement is performed when a valve of the heart is not functioning properly. It is replaced by an artificial valve that can perform the function of the damaged valve. This receives the 100% rating the entire time it is being treated in the hospital and for 6 months following discharge from the hospital. At the 6-month mark, the condition is reevaluated. It then either continues with the 100% rating or is rated based on the basic rating system.
– Code 7018: Cardiac pacemakers are implanted if the rhythm of the heart is too slow. This condition is rated 100% for the first 2 months following the surgery. After that, it is rated under the base condition that caused the irregular heart rhythm: irregular heart rhythm: supraventricular arrhythmias, ventricular arrhythmias, or an atrioventricular block. The minimum rating for a condition requiring a pacemaker is 10%. If a defibrillator is implanted, then it is rated under code 7011.
– Code 7019 Cardiac transplantation, a heart transplant, is rated 100% for one year from the date of admission to the hospital. After the one-year period, the condition is then reevaluated and rated on the basic rating system. The absolute minimum rating for this condition is 30%.
The following conditions do not have the 100% rating periods described for the above conditions. Instead, these are immediately rated on the basic heart rating system.
– Code 7003: Pericardial adhesions occur when the sac surrounding the heart sticks to the heart muscle and restricts its pumping action.
– Code 7004: Syphilitic heart disease occurs many years after the initial infection of syphilis. It causes inflammation in the heart that restricts blood flow to the heart itself. It can also cause syphilitic aortic aneurysms, which are rated under code 7110.
– Code 7005: Ischemic heart disease, Arteriosclerotic heart disease, Atherosclerotic heart disease, or Coronary artery disease all affect the coronary arteries. Arteriosclerosis is the thickening and hardening of the walls of the arteries, atherosclerosis is the narrowing and hardening of the arteries, and coronary artery disease is the blocking of the arteries from the build up of plaque. Often coronary artery disease is present with the other two. Coronary artery disease must be clearly documented to rate this condition.
– Code 7007: Hypertensive heart disease is caused by high blood pressure. Hypertension over many years can result in left ventricular hypertrophy and/or heart failure.
– Code 7015: Atrioventricular block occurs when the electrical impulses that allow the different parts of the heart to communicate and function are blocked. This must be associated with other evidence of heart disease to be considered unfitting. It is rated on the basic rating system with one addition: if a pacemaker is required, it is rated 10%.
– Code 7020: Cardiomyopathy is the deterioration of the heart muscle and its functioning for any reason. Any heart condition that is not covered by the other heart codes is rated here.
Other Heart Conditions
Cor pulmonale, the failure of the right side of the heart, is not a condition in and of itself, but is a result of another condition. Because of this, cor pulmonale is not ratable, but the underlying condition that causes it can be rated including sleep apnea.
Code 7010: Supraventricular arrhythmias are abnormal heart rhythms, most commonly too fast, that are located in the heart’s two upper chambers. If episodes of abnormal heart rhythms occur 5 or more times a year, then it is rated 30%. A 10% rating is given if episodes of abnormal rhythm occur 1 to 4 times a year or if there is permanent atrial fibrillation with no evidence of other heart diseases or conditions. All episodes must be properly documented by an ECG test.
Code 7008: Hyperthyroid heart disease occurs when the thyroid produces too much thyroid hormone. This can affect the blood pressure, how the heart consumes oxygen, and how much blood the heart can pump. This condition is rated on whichever heart code best describes the overall condition.
All other heart conditions will be rated analogously (see the Analogous and Equivalent Codes page) with one of the above ratings. The bottom line rule is to rate any condition under the code that BEST describes it, even if it is not exact. If a heart condition does not easily fit under one of the specific heart codes, then it is rated as cardiomyopathy under code 7020.
BASIC RATING FORMULA FOR HEART CONDITIONS
(Including Ischemic, Syphilitic, Arteriosclerotic, Atherosclerotic Heart Disease.):
PERCENTAGE
DESCRIPTION
The majority of heart conditions are rated based on a set rating system.
100%
• The condition scores 3 METs or less on an MET test and causes shortness of breath, fatigue, chest pain, dizziness or fainting (heart failure symptoms)
60%
• The condition scores 3.1 to 5 METs and causes shortness of breath, fatigue, chest pain, dizziness or fainting
30%
• The condition scores 5.1 to 7 METs on an MET test and causes shortness of breath, fatigue, chest pain, dizziness or fainting –OR-
• Evidence (x-ray, electro-cardiogram, or echocardiogram) of hypertrophy or dilation. An electro-cardiogram by itself can prove hypertrophy, but is not enough to prove dilation.
10%
• The condition scores 7.1-10 METs and causes shortness of breath, fatigue, chest pain, dizziness or fainting –OR-
• Continuous medication is required and clearly recorded by physician (including PRESCRIBED aspirin therapy).
Some heart conditions are rated at a temporary 100% including:
• Coronary bypass surgery (3 months temp 100%).
• Heart transplant (minimum 12 months temp 100% then 30% minimum)
• Implantable Cardioverter-Defibrillators (AICD's) (100% after surgery)
• Heart valve replacement/prosthesis (3 months temp 100%)
• Myocardial infarction (3 months temp 100%)
• Valvular heart disease (including rheumatic heart disease), Endocarditis, or Pericarditis (100% during infection and 3 months following cessation of treatment)
• Implantable cardiac pacemakers (100% for 1 month following hospital discharge for implantation or re-implantation. 10% after or based on residuals including supraventricular tachycardia, sustained ventricular arrhythmias and atrioventricular block.
NOTE: It is very important that the physician performing your exam gets an MET (Metabolic Equivalent of Task) test done for ANY heart condition. An MET test(exercise test or stress test), checks for how much oxygen is being used by the body to perform increasingly strenuous tasks. There are a very few cases where an MET test is not required, but the majority of the time it is essential to getting a proper heart rating. Be proactive and make sure an MET test is done! If the Veteran is unable to perform the MET test, a physician can submit a question only test.
NOTE: The claim should also include personal, spouse, family and co-worker statements on how the heart condition affects the Veteran’s daily activities and quality of life. Dates and times of symptoms are important as valid lay evidence.