Proposed Changes to the Digestive System

Proposed Changes to the Digestive System Ratings

On January 11th, 2022, the VA published proposed changes to the ratings of the Digestive System.

The following are the VA’s new proposed changes to the ratings for the Digestive System. The changes are fairly extensive, so we’ll walk through each, one at a time.

For each condition, the small, indented parts are the codes as they are right now. Click on the links to be taken to the discussion of that code on our site. After the current code, we’ll discuss the proposed changes and the VA’s justification.

COMMENTING IS CLOSED:

AQ90-Proposed Rule-Schedule for Rating Disabilities: The Digestive System

VA target date of February 2024 for final rule publication.

The following are the VA’s new proposed changes to the ratings for the Digestive System. The changes are fairly extensive, so we’ll walk through each, one at a time.

First, we need to start with some definitions of terms used in many of the proposed rating requirements.

· Baseline weight: The average weight noted in your medical records for the 2 years before the start of the weight loss/illness. If that information is not available and you are within 2 years post-discharge, then the weight recorded at your discharge physical will be used. When neither of these options work, then it will be estimated using the BMI Table or the Hamwi Formula, whichever is most favorable to you.

· Minor weight loss: The involuntary loss of 10-20% of your baseline weight. This weight loss must be present for at least 3 months to qualify, and there must be related symptoms like decreased food intake or an obvious decrease in the quality of self-care and work tasks.

· Substantial weight loss: The involuntary loss of 21% or more of your baseline weight. This weight loss must be present for at least 3 months to qualify, and there must be an obvious decrease in the quality of self-care and work tasks.

· Inability to gain weight: Substantial weight loss with the inability to regain it despite correctly following your doctor’s prescribed therapy.

· Undernutrition: The inability of the body to get, keep, or utilize essential nutrients, resulting in abnormal tissues or organ function. Symptoms may include swelling, nerve pain, weakness, numbness, muscle wasting, a BMI below normal range, etc.

· Prescribed dietary modification: Adjustments in your diet eaten via the mouth (liquids-only, etc.) that are officially prescribed by your physician.

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-Current Rule- The following codes cannot be used together (only one of them can be used at a time): 7301-7329, 7331, 7342, and 7345-7348. If you have two or more of these conditions, use the code that best reflects the overall disability. In cases where a rating under the chosen code does not adequately rate the severity of the overall disability, then the rating may be raised to the next higher rating.

-Proposed Rule- The following codes cannot be used together (only one of them can be used at a time): 7301-7329, 7331, 7342, 7345-7350, 7352, and 7355-7357. If you have two or more of these conditions, use the code that best reflects the overall disability. In cases where a rating under the chosen code does not adequately rate the severity of the overall disability, then the rating may be raised to the next higher rating.

The VA isn’t changing this rule itself, but proposes adding to it many of the new proposed codes we discuss below.

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-Current- Code 7200: If there is an injury to the mouth, it is rated on how it affects the ability to chew food and/or on any visible disfigurement to the face.

-Proposed- Code 7200: If there is a soft-tissue injury to the mouth (not including the tongue and lips), it is rated on how it affects the ability to chew food and/or on any visible disfigurement to the face.

The only proposed change to this code is to clarify that it is for soft-tissue injuries of the mouth only. The tongue and lips already have their own separate codes, as do bone and dental conditions.

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-Current- Code 7201: Any injury to the lips is rated under code 7800 as a disfiguring scar.

-Proposed- Code 7201: Any injury to the lips is rated either under code 7800, as a disfiguring scar, or code 7804, as a painful or unstable scar.

The VA proposes adding code 7804, painful or unstable scars, as a rating option. In reality, this has always been a rating option, but the change will make the option clearer to the rating authorities.

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-Current- Code 7202: The tongue can only be rated if a part of it has been lost. If half or more of the tongue is gone, then it is rated 60%. This rating can increase to 100% if the loss of the tongue makes it impossible to speak. If any amount of loss of the tongue causes significant trouble speaking, the minimum rating is 30%.

-Proposed- Code 7202: The tongue can only be rated if some or all of it has been lost. If at least a part is missing, it is then rated on how the loss affects the ability to swallow.

A 100% rating is given if the body cannot get any nutrition via the mouth because damage to the tongue is so severe that it is impossible to swallow.

A 60% rating is given if swallowing is permanently impaired and requires prescribed dietary modification in order for the body to get nutrition via the mouth.

A 30% rating is given if swallowing is permanently impaired but does not require prescribed dietary modification in order for the body to get nutrition via the mouth.

This condition may qualify for Special Monthly Compensation (k) if it results in the inability to speak.

The VA proposes significant changes to this code. The current rating system rates the loss of the tongue on the amount lost and the ability to speak, but does not take into account the impact on the ability to eat food and thus provide nutrition to the body. The VA is proposing to adjust the ratings to reflect the greater disability the lack of nutrition can cause. The inability to speak will still be covered by SMC-K.

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-Current- Code 7203: A stricture of the esophagus occurs when the esophagus narrows and tightens, making it hard to swallow. If it is so narrowed that only liquids can be swallowed, it is rated 50%. If only being able to swallow liquids also causes a serious decrease in overall health, then it is rated 80%. If the esophagus is seriously narrowed, but some things besides liquids can also be swallowed, then it is rated 30%.

-Proposed- Code 7203: A stricture of the esophagus occurs when the esophagus narrows and tightens, making it hard to swallow. Many conditions can cause strictures, so any condition where that is the main symptom is rated here, including esophagitis and any esophageal condition that requires sclerotherapy.

In order to qualify for a rating under this code, there must be a clear history of strictures documented by an appropriate test (barium swallow, computerized tomography, or esophagogastroduodenoscopy).

The Ratings:

An 80% rating is given if the strictures are recurrent (the stricture returns within 4 weeks after it is resolved) or refractory (the stricture persists despite 5 or more dilation treatments performed at 2 week intervals), there is difficulty swallowing, it requires either surgical correction or a feeding tube placed directly into the stomach, and one or more of the following symptoms are present:

· aspiration (when something enters the airways or lungs by accident)

· undernutrition

· substantial weight loss

A 50% rating is given if the strictures are recurrent or refractory, there is difficulty swallowing, and one or more of the following treatments are required:

· dilation (a procedure that widens the narrowed portion of the esophagus) 3 or more times/year

· dilation using steroids at least once a year

· esophageal stent placement

A 30% rating is given if the strictures are recurrent or refractory and cause difficulty swallowing that requires dilation 1-2 times/year.

A 10% rating is given if the condition requires daily medications in order to swallow normally and there are no other symptoms.

A 0% rating is given if the condition does not cause daily symptoms or does not require daily medications.

If treatment of the condition results in damage to anything outside the digestive system, then that damage can be rated separately.

The VA is proposing massive changes to this code. The current rating requirements are a bit vague, so the VA’s proposed requirements remove a lot of the guesswork when applying the ratings. They are more specific and based on updated treatment options and common symptomology.

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-Current- Code 7204: Spasms of the esophagus can occur when the muscles in the esophagus are unable to move food down to the stomach, often causing chest pain and various troubles eating. If this condition can be fixed with dilation treatment, then it is not ratable. If it cannot, then it is rated as a stricture of the esophagus, code 7203.

-Proposed- Code 7204: Esophageal motility disorder (including achalasia, DES, cork-screw esophagus, esophageal rings, etc.) occurs when the muscles in the esophagus are unable to move food down to the stomach. It is rated under code 7203.

The main change for this code is to rename it from “spasms of the esophagus” to “esophageal motility disorder.” This title makes it clear that this code covers all conditions that affect the motion of the esophagus and its ability to deliver food to the stomach.

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Code 7205 for diverticulum of the esophagus will not change.

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-NEW Proposed Code- Code 7206: Gastroesophageal reflux disease (GERD) is a condition where the acid and food in the stomach travel up the esophagus. It is rated under code 7203.

Currently, GERD does not have its own code but is rated analogously under the code for hiatal hernia, which gives a rating of 30% for “regular episodes of pain in the upper abdomen, trouble swallowing, heartburn, the return of food into the back of the throat/mouth, and pain in the upper arm or shoulder.” The VA claims that GERD will be appropriately rated under the proposed ratings for 7203. This code, however, does not give ratings for any symptoms other than difficulty swallowing, so we are definitely going to bring this issue up in the comments we submit regarding these changes since the dominant symptoms of GERD are pain/heartburn/regurgitation, not difficulty swallowing, though that can result in more serious cases.

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-NEW Proposed Code- Code 7207: Barrett’s esophagus is a condition where abnormal cells form in the lower part of the esophagus.

If the build-up of cells causes the esophagus to narrow (stricture) or if the condition is no longer active due to treatment, it is rated under code 7203.

If the esophagus is not narrowed, but the abnormal cells are precancerous (high-grade dysplasia), it is rated 30%.

If the esophagus is not narrowed and the abnormal cells are not precancerous (low-grade dysplasia), it is rated 10%.

If the condition becomes malignant, it is rated under code 7343.

Currently, Barrett’s Esophagus does not have its own code but is rated analogously under code 7203. The VA proposes to add this code in order to better cover the range of symptoms since not all cases cause strictures.

-Current- Code 7301: Adhesions of the peritoneum are areas of scar tissue that cause the surface of the peritoneum to stick to the surface of organs. This can cause the organs to twist out of shape and thus function poorly. Adhesions are only ratable if abdominal surgeries have been performed or if injury or an infectious disease has affected the inside of the abdomen, and if two or more of the following is present: 1) a slowing down of digestive functioning, 2) the digestive tract is partially or completely blocked, 3) acid and fluids in the digestive tract come up into the esophagus (reflux), and 4) pain.If the adhesions develop after a ruptured appendix, an ulcer that burns the peritoneum, or a surgery that required drainage out of the abdomen, and they cause the digestive path to become partially blocked, with frequent episodes of swelling and pressure in the abdomen, and nausea or vomiting, it is rated 50%.

If the adhesions cause the digestive path to become partially blocked, and it is proven by a Barium Meal Test, and there are only occasional episodes of pain, it is rated 30%.

If there is tight pain when moving the abdomen (it feels like something is pulling inside), or if there are occasional episodes of swelling, bloating, nausea, and constipation, it is rated 10%.

If the condition is mild with few symptoms, it is rated 0%.

-Proposed- Code 7301: Adhesions of the peritoneum are areas of scar tissue from injuries, surgeries, diseases, or infections, that cause the surface of the peritoneum to stick to the surface of organs. This can cause the organs to twist out of shape and thus function poorly.

An 80% rating is given if the condition causes a partial bowel obstruction that cannot be fixed by surgery or treatment, or if it requires Total Parenteral Nutrition (a liquid mixture of essential nutrients injected directly into the blood).

A 50% rating is given if the condition is resistant to treatment or comes back after treatment, it requires hospitalization at least once a year, it requires prescribed dietary modification, and it has at least one of the following symptoms: stomach pain, nausea, vomiting, colic, constipation, or diarrhea.

A 30% rating is given if the condition is resistant to treatment or comes back after treatment, it requires prescribed dietary modification, and it has at least one of the following symptoms: stomach pain, nausea, vomiting, colic, constipation, or diarrhea.

A 10% rating is given if the condition is resistant to treatment or comes back after treatment, and it has at least one of the following symptoms: stomach pain, nausea, vomiting, colic, constipation, or diarrhea.

If there are no symptoms, it is rated 0%.

The proposed changes to this code are meant to reflect the more common long-term disabilities caused by this condition with modern treatments. Because some cases are resistant to any treatment at all, the VA proposes adding an 80% rating option to ensure appropriate rating of the overall disability.

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-NEW Proposed Code- Code 7303: All Chronic side effects of surgeries to the esophagus, stomach, pancreas, and small intestine (except resection, code 7328) are rated under this code.

Note: If pancreatic surgery results in a vitamin or mineral deficiency, it is rated under the appropriate Nutritional Deficiency code.

The Ratings:

An 80% rating is given if the condition requires Total Parenteral Nutrition or Enteral Nutrition for more than 30 days in a row during the last six months.

A 50% rating is given if one or more of the following is present:

· Daily vomiting that cannot be controlled by medication or prescribed dietary modification

· Watery bowel movements 6 or more times/day

· Unpredictable or uncontrollable explosive bowel movements

· Light-headedness and sweating after eating and medications needed to treat dumping syndrome (the stomach passes food into the small intestine much faster than normal) or gastroparesis (the stomach passes food into the small intestine much slower than normal)

A 30% rating is given if two or more of the following is present:

· Vomiting two or more times/week or vomiting that cannot be controlled by treatment

· Discomfort/pain within an hour of eating, with prescribed dietary modification

· Watery bowel movements 3-5 times/day

A 10% rating is given if there is nausea or vomiting that can be controlled by ongoing treatment.

A 0% rating is given if there are no symptoms.

The VA is proposing this new code to ensure that side effects of surgeries are properly and consistently rated based on their most common disabling symptoms.

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-Current- Both code 7304 and 7305 are rated by the same rating system.

Code 7304: A gastric ulcer is an ulcer in the stomach.

Code 7305: A duodenal ulcer is an ulcer in the lower part of the stomach and beginning of the small intestine (the duodenum).

The ratings:

If the pain cannot be fully relieved by treatment, there is occasional vomiting, blood in the vomit or in the feces, anemia, weight loss and an overall serious decline in health, it is rated 60%. If there is a definite decrease in overall health with anemia and weight loss, or if there are repeated periods of required bed rest prescribed by a physician that average about 10 days or more at least 4 or more times a year, it is rated 40%. If there are repeated periods of severe symptoms that average about 10 days or more 2 or 3 times a year, or if there are constant moderate symptoms, it is rated 20%. If it is mild with episodes of symptoms once or twice a year, it is rated 10%.

Code 7306: A marginal ulcer in both the stomach and the small intestine is an ulcer caused by healthy cells dying.

If there is constant or periodic severe pain that cannot be relieved by treatment, occasional vomiting, blood in the vomit or feces, and weight loss that is completely disabling, it is rated 100%. If the same symptoms are present, but they are less frequent or severe and cause a serious but not complete disability, it is rated 60%. If there are episodes at least once a month that can be partially or completely relieved by treatment of vomiting, pain or blood in the feces, it is rated 40%. If there are moderate episodes several times a year, it is rated 20%. If there are mild or short episodes once or twice a year, it is rated 10%.

-Proposed- Code 7304: Any ulcer in the stomach or small intestine (“peptic ulcer”) is rated under this code.

A 60% rating is given if there is constant abdominal pain with either regular vomiting or occasional blood in the vomit or feces, and at least one hospitalization was required in the past 12 months for anemia.

A 40% rating is given if there are four or more episodes in the past 12 months of abdominal pain, nausea, or vomiting. Each episode must have lasted for at least three days and required daily prescribed medication.

A 20% rating is given if there are one to three episodes in the past 12 months of abdominal pain, nausea, or vomiting. Each episode must have lasted for at least three days and required daily prescribed medication.

A 0% rating is given if there are no episodes of symptoms in the past 12 months.

If the condition requires surgery to fix tears and/or bleeding, then it is rated 100% for the first three months after surgery. It is then re-evaluated and rerated on any remaining symptoms.

The VA proposes removing codes 7305 and 7306 and combining all the ratings for ulcers of the stomach and small intestine under code 7304. Modern medicine treats these ulcers similarly and they manifest with similar symptoms, so this would enable more consistent rating across the board.

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-Current- Code 7307: Chronic hypertrophic gastritis is the swelling of the stomach and glands that continues over a long period of time and often leads to cancer. To be rated under this code, the condition must be diagnosed and confirmed by Endoscopy. If there is severe bleeding in the stomach or large tears or breaks (ulcers) in the stomach wall, it is rated 60%. If there are small tears or breaks in the stomach wall and symptoms like stomach pain, it is rated 30%. If there are nodular Lesions in the stomach and symptoms like stomach pain, it is rated 10%.

-Proposed- Code 7307: Chronic gastritis (including Helicobacter pylori infection, Zollinger-Ellison syndrome, and portal hypertensive gastropathy with bleeding) is the swelling of the stomach and glands that continues over a long period of time and often leads to cancer. It is rated under code 7304.

The VA proposes to remove outdated medical testing and treatments from this code and to have it rated under the code for ulcers since gastritis presents similar symptoms.

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-Current- Code 7308: A gastrectomy is the full or partial removal of the stomach which could lead to many Postgastrectomy Syndromes. If the syndromes are severe and cause nausea, sweating, problems with blood circulation after meals, diarrhea, low blood sugar symptoms like seizures or slow brain functioning, and weight loss with malnutrition and anemia, it is rated 60%. If the syndromes are moderate and cause occasional mild problems with blood circulation after meals, diarrhea and weight loss, it is rated 40%. If the syndromes are mild and only cause mild problems with blood circulation every now and then or if there are constant but mild symptoms like diarrhea, weight loss or low blood sugar, it is rated 20%.

-Proposed- Code 7308: A gastrectomy is the full or partial removal of the stomach which could lead to Postgastrectomy Syndrome. It is rated under code 7303.

Since the VA is wanting to create the new code 7303 for all symptoms remaining after surgeries, including stomach surgeries, then this code does not need to have its own rating system. It can simply be rated under code 7303.

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-Current- Code 7309: Stenosis of the stomach is when the stomach becomes abnormally narrowed. This most commonly occurs at the lower part of the stomach (pyloris) where food passes from the stomach to the small intestine. This condition is rated as a gastric ulcer.

-Proposed- Code 7309: Stenosis of the stomach is when the stomach becomes abnormally narrowed. This most commonly occurs at the lower part of the stomach (pyloris) where food passes from the stomach to the small intestine. This condition most often occurs after surgery. In these cases, it is rated under code 7303. Otherwise, it is rated as an ulcer, code 7304.

-Current- Code 7310: Any lasting symptoms after an injury to the stomach are rated as peritoneal adhesions, code 7301.

-Proposed- Code 7310: Any lasting symptoms after an injury to the stomach are rated under code 7301 (adhesions are not required). If surgery has been performed, then it is rated under code 7303.

The only significant proposed change to these codes is to add code 7303 as a rating option after surgeries.

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Code 7311 for symptoms remaining after injury to the liver remains exactly the same.

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-Current- Code 7312: Cirrhosis of the Liver, Primary Biliary Cirrhosis, and the cirrhotic phase of Sclerosing Cholangitis are all rated under this code. For any of these conditions to qualify for a rating, proper tests like a biopsy and liver function test must be performed.

If the condition causes weakness, Significant Weight Loss, and continuous Jaundice, or if there is one or more of the following that cannot be fixed by treatment: 1) swelling in the abdomen, 2) mental disturbances like confusion, loss of consciousness and coma, or 3) bleeding in the abdomen from the blood vessels or Portal Gastropathy, it is rated 100%.

If the condition has caused 2 or more episodes of swelling in the abdomen, mental disturbances, or bleeding in the abdomen with periods in between these episodes where the disease is not active, it is rated 70%. If the condition has caused 1 episode of swelling in the abdomen, mental disturbances, or bleeding in the abdomen, it is rated 50%. If there is high blood pressure in the Portal Vein and swelling in the spleen with weakness, anorexia, stomach pain, uneasiness, and minor weight loss, it is rated 30%. If there are symptoms like weakness, anorexia, stomach pain and uneasiness, it is rated 10%.

-Proposed- Code 7312: Cirrhosis of the Liver is permanent damage to the liver, often caused by alcohol or hepatitis. In order to qualify, the liver dysfunction must be confirmed through radiology, biopsy, or biochemical studies.

This condition is rated on the MELD Score (Model for End-Stage Liver Disease). If a MELD Score cannot be calculated, then it is rated on the symptoms.

The MELD Score Ratings:

A 100% rating is given for a MELD Score of 15 or higher.

A 60% rating is given for a MELD Score between 11.1 and 14.9.

A 30% rating is given for a MELD Score of 10-11.

A 10% rating is given for a MELD Score between 6.1 and 9.9.

The Symptom Ratings:

A 100% rating is given if there are continuous debilitating symptoms, weakness, and at least one of the following:

· Fluid in the abdomen

· History of infected fluid in the abdomen (spontaneous bacterial peritonitis)

· Encephalopathy (brain dysfunction)

· Bleeding within the digestive tract

· Impaired ability to form blood clots

· Portal gastropathy (changes in the stomach lining)

· Hepatopulmonary syndrome (dilation in the lungs that affects oxygen absorption)

· Hepatorenal syndrome (impairment of kidney function)

A 60% rating is given if there is daily fatigue and at least one episode/year of one the following:

· Bleeding within the digestive tract

· Portal gastropathy (changes in the stomach lining)

· Encephalopathy (brain dysfunction)

A 30% rating is given if there are signs of high blood pressure in the portal vein (like an enlarged spleen, fluid in the abdomen, etc.) and at least one of the following:

· weakness

· anorexia

· abdominal pain

· malaise

A 10% rating is given if there is at least one of the following:

· weakness

· anorexia

· abdominal pain

· malaise

A 0% rating is given if there are no symptoms.

Note: If hepatocellular carcinoma occurs with cirrhosis, then only a single rating is given under code 7343 for malignant cancer.

The VA is proposing significant changes to the ratings of cirrhosis in order to take into account the now widely-used MELD Score system. The ratings based on symptoms have also been updated to reflect modern symptomology based on current treatments, etc.

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-Current- Code 7314: Chronic cholecystitis is the constant swelling of the gallbladder most often caused by gallstones. The most common symptom is severe pain near the bottom of the ribs on the right side. In most people, the gallbladder can be removed without serious side effects. If there are frequent severe attacks of pain, it is rated 30%. If there is heartburn and occasional attacks of severe pain, it is rated 10%. If there are only occasional mild symptoms, it is rated 0%.

-Proposed- Code 7314: Chronic biliary tract disease is a group of conditions that affect the liver and gallbladder in the production and use of bile. Common conditions rated under this code include cholangitis, biliary strictures, sphincter of Oddi dysfunction, bile duct injury, choledochal cyst, etc. Primary sclerosing cholangitis is not rated under this code, but under code 7345.

The Ratings:

“Attacks” is defined as episodes of upper right quadrant pain with nausea and vomiting. All attacks must be documented by a medical professional.

A 30% rating is given if there are 3 or more attacks in the past year, or if biliary tract strictures required widening at least once during the past year.

A 10% rating is given if there are 1-2 attacks in the past year.

A 0% rating is given if there have been no attacks in the past year.

All conditions that affect the biliary tract cause symptoms similar to cholecystitis, and so the VA proposes adjusting this code to cover all of these conditions. The adjustments to the ratings are intended to clarify currently vague requirements for more consistent ratings.

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Code 7315 for chronic cholelithiasis will continue to be rated under code 7314.

Code 7316 for chronic cholangitis will be removed as this condition will be covered under the proposed code 7314.

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-Current- Code 7317: Any lasting symptoms after an injury to the gallbladder are rated as peritoneal adhesions.

-Proposed- Code 7317: Any lasting symptoms after an injury to the gallbladder are rated as either peritoneal adhesions (code 7301, no adhesions required), biliary tract disease (code 7314), or side effects of gallbladder removal (code 7318), whichever best covers the disability.

The VA proposes adding additional rating options for this code in order to ensure that the symptoms are appropriately rated.

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-Current- Code 7318: The removal of the gallbladder normally does not cause any serious side effects, but complications are always possible. If the removal of the gallbladder causes severe symptoms, like pain and nausea, it is rated 30%. If there are only mild symptoms, it is rated 10%. If there are no symptoms, it is rated 0%.

-Proposed- Code 7318: The removal of the gallbladder normally does not cause any serious side effects, but complications are always possible.

A 30% rating is given if there is frequent abdominal pain (especially after a meal or at night) and 3 or more watery bowel movements/day.

A 10% rating is given if there is occasional abdominal pain and 1-2 watery bowel movements/day.

A 0% rating is given if there are no symptoms.

The VA proposes to make the rating requirements more specific for this code in order to avoid confusion and keep ratings consistent.

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-Current- Code 7319: Irritable colon syndrome (a.k.a. irritable bowel syndrome, spastic colitis, mucous colitis, etc.) is a condition where there is significant stomach pain, bloating and often changes in the pattern of bowel movements with diarrhea or constipation. There is no known cause of this condition.

If it is severe with diarrhea, or if it alternates between diarrhea and constipation, with stomach pains, it is rated 30%. If there are frequent episodes of abnormal bowel movements with stomach pain, it is rated 10%. If there are mild abnormal bowel movements with occasional stomach pain, it is rated 0%.

-Proposed- Code 7319: Irritable bowel syndrome (IBS) is a condition where there is significant stomach pain, bloating, and often changes in the pattern of bowel movements with diarrhea or constipation.

Note: This code covers all conditions whose main symptoms are things like bloating, indigestion, constipation, and diarrhea. Conditions that affect the actual structures and functions of the bowels (paralysis/motility, strictures, etc.) are rated under the appropriate codes.

A 30% rating is given if there is stomach pain at least 1 day/week for the past 3 months, and two or more of the following:

· Change in bowel movement frequency (more often or less often)

· Change in stool form (harder or softer than usual)

· Change in stool passage (difficult to get out or comes out too easily)

· Bowel movements contain a large amount of mucus

· Physical stomach bloating

· Feeling bloated

A 20% rating is given if there is stomach pain at least 3 days/month for the past 3 months, and two or more of the following:

· Change in bowel movement frequency (more often or less often)

· Change in stool form (harder or softer than usual)

· Change in stool passage (difficult to get out or comes out too easily)

· Bowel movements contain a large amount of mucus

· Physical stomach bloating

· Feeling bloated

A 10% rating is given if there is stomach pain at least once in the past 3 months, and two or more of the following:

· Change in bowel movement frequency (more often or less often)

· Change in stool form (harder or softer than usual)

· Change in stool passage (difficult to get out or comes out too easily)

· Bowel movements contain a large amount of mucus

· Physical stomach bloating

· Feeling bloated

The VA’s proposed changes for this code update terminology to modern usage (everyone just calls it IBS these days) and makes the rating requirements clearer and more specific than the currently vague severe/mild/frequent/etc.

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The VA proposes to remove codes 7321, 7322, and 7324 for various infectious intestinal conditions. When the VA changed the Infectious Diseases ratings in 2019, they created new codes that now cover these conditions, so these codes are no longer needed. The ratings would remain consistent for veterans already rated under these codes, the codes themselves would simply change.

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-Current- Code 7323: Ulcerative colitis (a.k.a. inflammatory bowel disease) is a disease of the colon where tears or open sores form in the tissues of the colon and cause bloody diarrhea.

If it is very severe and constant and causes serious malnutrition, anemia, and overall disabling bad health or if it causes a severe Liver Abscess, it is rated 100%. If it is severe, but not constant, with many attacks a year that cause malnutrition which then causes overall bad health that cannot be fully recovered during the periods in between attacks, it is rated 60%. If it is somewhat severe and causes some attacks a year, but less than a severe condition, it is rated 30%. If there are only occasional attacks, it is rated 10%.

-Proposed- Code 7323: Ulcerative colitis, a type of inflammatory bowel disease, is a disease of the colon where tears or open sores form in the tissues of the colon and cause bloody diarrhea. It is rated under code 7326.

The VA is proposing to create a new rating system under code 7326 specifically for inflammatory bowel disease, and so proposes to simply have all inflammatory bowel diseases, including ulcerative colitis, rated under that code since all present with similar symptoms and resulting disabilities.

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-Current- Code 7325: Chronic enteritis is the constant swelling of the small intestine. Symptoms include stomach pain, cramping, diarrhea, dehydration and fever. It is rated as irritable colon syndrome, code 7319 above.

-Proposed- Code 7325: Chronic enteritis is the constant swelling of the small intestine. Symptoms include stomach pain, cramping, diarrhea, dehydration, and fever. It is rated as irritable colon syndrome, code 7319, or inflammatory bowel disease, code 7326, whichever best covers the symptoms.

With the new proposed ratings under code 7326 for inflammatory bowel disease, the VA is proposing to add it as a second rating option for chronic enteritis in order to better cover the more severe symptoms this condition can sometimes cause.

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-Current- Code 7326: Chronic enterocolitis is the constant swelling of the colon and small intestine. It is rated as irritable colon syndrome.

-Proposed- Code 7326: Inflammatory bowel disease (including Crohn’s disease) is the constant swelling of any part of the gastrointestinal tract, most commonly the colon and small intestine. To be rated under this code, the condition must be diagnosed by an endoscopy or radiological studies.

A 100% rating is given if the condition does not respond to treatment and requires at least 1 hospitalization/year. It also must either result in the inability to work or cause regular stomach pain with two or more of the following:

· Diarrhea six or more times/day

· Rectal bleeding six or more times/day

· Repeated episodes of incontinence

· Repeated episodes of stomach bloating

A 60% rating is given if all of the following are present:

· Regular stomach pain

· Diarrhea 4-5 times/day

· Repeated signs of toxicity (like fever, fast heart rate, or anemia)

· Requires treatment with immunosuppressants or other biologic agents

A 30% rating is given if all of the following are present:

· Regular stomach pain

· Diarrhea 1-3 times/day

· Occasional signs of toxicity (like fever, fast heart rate, or anemia)

· Requires treatment with oral or topical medications

A 10% rating is given if all of the following are present:

· Regular stomach pain

· Diarrhea 1-3 times/day

· No signs of toxicity (like fever, fast heart rate, or anemia)

· Requires treatment with oral or topical medications

Note: If a colostomy (a surgical procedure that creates a new passageway from the rectum or anus to the outside of the body) is performed, then the remaining symptoms can either be rated under this code or under code 7329, whichever gives a higher rating.

Currently, the only rating option for enterocolitis is as irritable bowel syndrome, however, inflammatory bowel diseases present in significantly different ways. The VA therefore proposes creating a rating system specifically for inflammatory bowel diseases in order to ensure ratings that more appropriately reflect the most common symptoms of these conditions.

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-Current- Code 7327: Diverticulitis is a disease of the colon that causes pouches outside the colon to form and then swell. It can cause fever, pain, nausea, diarrhea and high white blood cell count. It is either rated as irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, whichever most closely describes the overall condition and symptoms.

-Proposed- Code 7327: Diverticulitis and diverticulosis are rated under this code. Diverticulosis is a disease of the colon that causes pouches to form in the walls of the colon. Diverticulitis occurs when the pouches become infected.

A 30% rating is given if stomach pain, fever, and an elevated white blood cell count requires at least one hospitalization in the past year, and one of more of the following:

· Internal bleeding

· Blockage in the colon

· A pus-filled infection (abscess)

· Swelling of the peritoneum

· Holes in the walls of the colon

A 20% rating is given if stomach pain, fever, and an elevated white blood cell count requires at least one hospitalization in the past year.

A 0% rating is given if the symptoms can be fully managed by diet and medication.

Note: If a colostomy (a surgical procedure that creates a new passageway from the rectum or anus to the outside of the body) or colectomy (removal of a portion of the colon) is performed to treat the condition, then the remaining symptoms can either be rated under this code or under code 7329, whichever gives a higher rating.

Currently, diverticulitis does not have its own rating options but is rated under other codes. The VA acknowledges, however, that diverticulitis has unique symptoms and side effects that are not properly covered by these rating options and so proposing a set of rating criteria specifically for this condition.

The VA also proposes adding diverticulosis to this code. Diverticulosis rarely, if ever, causes ratable symptoms, however, many cases ultimately become diverticulitis. Allowing it to be claimed and rated 0% under this code will allow for faster and easier rating increases in cases that do develop into diverticulitis.

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-Current- Code 7328: A resection of the small intestine is a procedure where all or a part of the intestine is removed. If the small intestine can no longer absorb enough nutrients to sustain the body, causing the overall health of the body to seriously decline (significant weight loss, serious nutritional deficiencies, etc.), it is rated 60%. If the small intestine can still absorb some nutrients, but not enough to maintain a healthy weight, it is rated 40%. If the small intestine can absorb enough nutrients, but there is diarrhea, anemia, and the inability to gain weight, it is rated 20%.

-Proposed- Code 7328: A resection of the small intestine is a procedure where all or a part of the intestine is removed. Short bowel syndrome, post-bariatric surgery, and mesenteric ischemic thrombosis are all rated under this code.

An 80% rating is given if the resection results in undernutrition and anemia that requires Total Parenteral Nutrition.

A 60% rating is given if the resection results in undernutrition and anemia that requires continuous medication, prescribed dietary supplements, and occasional Total Parenteral Nutrition.

A 40% rating is given if the resection causes diarrhea four or more times/day, resulting in undernutrition and anemia that requires continuous medication and prescribed dietary supplements.

A 20% rating is given if the resection causes diarrhea four or more times/day.

A 0% rating is given if there are no symptoms.

Note: If the condition results in high-output syndrome (when the body doesn’t absorb enough fluids, often resulting in the loss of electrolytes and dehydration), it can be rated under this code or under code 7329, whichever provides a higher rating.

The VA proposes updating these rating requirements to better reflect modern treatments and the more common long-term effects we see with these treatments, including adding a higher 80% rating level for severe cases. The VA also instructs additional conditions to be rated under this code for clarity and consistency.

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-Current- Code 7329: A resection of the large intestine is a procedure where all or a part of the intestine is removed. If the procedure causes severe symptoms, like the inability to pass feces or constant dehydration, that significantly affect the overall health, it is rated 40%. If is causes definite symptoms, like regular diarrhea and the need to drink more water than normal, it is rated 20%. If there are only mild symptoms, like increased thirst, it is rated 10%. If the symptoms are only caused by scar tissue from the procedure, the entire condition is rated under code 7301.

-Proposed- Code 7329: A resection of the large intestine (a.k.a. “colectomy”) is a procedure where all or a part of the intestine is removed. It can either be rated on the below criteria or under code 7326, whichever results in a higher rating.

A 100% rating is given if the colon is completely removed and all of the following are present:

· An ileostomy (the end of the small intestine is routed to the outside of the abdomen)

· High-output syndrome

· Dehydration requiring IV treatment three or more times in the last year

A 60% rating is given if the colon is completely removed but it doesn’t result in high-output syndrome.

A 40% rating is given if a portion of the colon is removed and the remaining end is permanently routed to the outside of the abdomen (colostomy).

A 20% rating is given if the ileocecal valve (connects the small intestine and colon) and a portion of the colon is removed with the remaining ends of the intestines connected together, and there is diarrhea 3 or more times/day on a regular basis.

A 10% rating is given if a portion of the colon is removed with the remaining ends connected together.

The current ratings for this code max out at a 40% rating, not properly reflecting the severity of disability resulting from a total colectomy. The VA proposes adding additional rating options for a total colectomy and to more clearly specify the rating requirements for partial colectomies.

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-Current- Code 7330: A fistula of the intestine (large or small intestine), is an abnormal passageway from the intestine to another organ or to the outside of the body. If surgery was attempted to repair the fistula, but the surgery was not fully successful or the fistula re-developed, it is ratable under this code. If the surgery successfully repaired it, then it is rated under code 7301.

If a very large amount of feces frequently moves through the fistula, it is rated 100%. If feces constantly or frequently move through the fistula, it is rated 60%. If a small amount of feces moves through the fistula every now and then, it is rated 30%.

-Proposed- Code 7330: A fistula of the intestine (large or small intestine), is an abnormal passageway from the intestine to the outside of the body.

A 100% rating is given if it requires Total Parenteral Nutrition. This rating can also be given if it requires Enteral Nutrition (a liquid mixture of essential nutrients delivered through a feeding tube) and one or more of the following:

· Four or more ostomy bags worth of discharge every day

· Ten or more pad changes every day

· BMI less than 16 and regular drainage for more than 1 month in the last year

A 60% rating is given if it requires Enteral Nutrition and one or more of the following:

· Less than four ostomy bags worth of discharge every day

· Less than ten pad changes every day

· BMI between 16-18 and regular drainage for more than 2 months in the last year

A 30% rating is given if there is intermittent discharge with regular drainage for more than 3 months in the last year.

The current ratings for this code are based on vague amounts of feces coming from the fistula. In order to more clearly reflect the real effect of this condition, including the nutritional implications, the VA is proposing these changes.

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Code 7331 for tuberculosis of the peritoneum remains exactly the same.

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-Current- Code 7332: Poor sphincter control (a.k.a. “incontinence”) occurs when the sphincter muscle, a muscle that encircles the opening of the rectum and anus, cannot contract properly or be controlled, thus leading to feces exiting the body at unwanted times.

If there is no sphincter control at all, it is rated 100%. If there is a significant amount of stuff always leaking out of the anus and frequent uncontrollable bowel movements, it is rated 60%. If there are only occasional uncontrollable bowel movements that require a pad or other materials to be worn, it is rated 30%. If there are not any uncontrollable bowel movements, but there is constant slight leakage or occasional moderate leakage, it is rated 10%. If there is no leakage at all, it is rated 0%.

If there is a loss of sphincter control and both legs are amputated or paralyzed, then a rating of 100% is always given, regardless of improvement with therapy. This is also the case if the loss of sphincter control is due to a spinal cord disease or injury.

-Proposed- Code 7332: Loss of sphincter control (a.k.a. “incontinence”) occurs when the sphincter muscle, a muscle that encircles the opening of the rectum and anus, cannot contract properly or be controlled. This results in either the inability to expel feces when desired or feces exiting the body at unwanted times.

A 100% rating is given if there is a complete loss of sphincter control and one or more of the following:

· The condition is unresponsive to a prescribed bowel program and requires surgery, medication (more than just laxatives), and prescribed dietary modification

· The condition is unresponsive to a prescribed bowel program and requires the manual removal of feces (“digital stimulation”), medication (more than just laxatives), and prescribed dietary modification

· Every day, there are two or more uncontrolled liquid and/or solid bowel movements that require pads to be changed at least twice/day

A 60% rating is given if there is a complete or partial loss of sphincter control and one or more of the following:

· The condition is partially responsive to a prescribed bowel program and requires surgery, medication (more than just laxatives), and prescribed dietary modification

· The condition is partially responsive to a prescribed bowel program and requires the manual removal of feces (“digital stimulation”), medication (more than just laxatives), and prescribed dietary modification

· Every week, there are two or more uncontrolled liquid and/or solid bowel movements that require pads to be worn at least twice/week

A 30% rating is given if there is a complete or partial loss of sphincter control and one or more of the following:

· The condition is responsive to a prescribed bowel program and requires the manual removal of feces (“digital stimulation”), medication (more than just laxatives), and prescribed dietary modification

· Every month, there are two or more uncontrolled liquid and/or solid bowel movements that require pads to be worn at least twice/month

A 10% rating is given if there is a complete or partial loss of sphincter control and one or more of the following:

· The condition is responsive to a prescribed bowel program and requires medications or prescribed dietary modification

· Every 6 months, there are one or more uncontrolled liquid and/or solid bowel movements that require pads to be worn at least once.

A 0% rating is given if there are no symptoms.

The VA proposes to adjust these ratings to get rid of vague terminology, clearly clarify that incontinence covers both unwanted leakage and the inability to expel feces when desired, and to align the ratings options with the Cleveland Clinic Incontinence Scale, which is widely used throughout the modern medical community. This Scale scores the severity of incontinence based not only on the incontinence itself, but on lifestyle modifications and medical treatments needed to treat it (dietary changes, surgeries, medications, etc.).

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-Current- Code 7333: A stricture of the rectum or anus is a patch of scar tissue that narrows the openings of the rectum and anus, thus making it difficult or impossible for feces to pass through. If a colostomy, a surgical procedure that creates a new passageway from the rectum or anus to the outside of the body, is required, it is rated 100%. If the scar tissue seriously decreases the space in the rectum or anus, or if there is extensive leakage, it is rated 50%. If the scar tissue only moderately decreases the space in the rectum or anus, or if there is moderate but constant leakage, it is rated 30%.

-Proposed- Code 7333: A stricture of the rectum or anus is a patch of scar tissue that narrows the openings of the rectum and anus, thus making it difficult or impossible for feces to pass through. Dyssynergic defecation and functional constipation are rated under this code.

Note: If an ostomy (a surgical procedure that creates a new passageway from the rectum or anus to the outside of the body) is performed, it is rated under code 7329.

A 100% rating is given if the anus is completely unable to open to expel solid waste.

A 60% rating is given if the anus is only able to open less than 50% of the way and there is pain and straining during defecation.

A 30% rating is given if the anus is able to open to 50% or more and there is straining during defecation.

A 10% rating is given if the anus is narrowed, and there may be straining, but overall the symptoms are managed by dietary modification.

The VA proposes to adjust these ratings to get rid of vague terminology to ensure consistency in rating.

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-Current- Code 7334: A prolapse of the rectum occurs when the muscles or tissues holding the rectum in place weaken and the rectum slips out of place and may slip down out of the anus. If the rectum is completely out of the anus and stays out, it is rated 50%. If it doesn’t slip all the way out, but it stays out or slips out frequently, it is rated 30%. If it is only a little out of place and doesn’t slip out of the anus, but does cause leakage, it is rated 10%.

-Proposed- Code 7334: A prolapse of the rectum occurs when the muscles or tissues holding the rectum in place weaken and the rectum slips out of place and may slip down out of the anus.

This condition is rated on the following criteria or under code 7332 if the loss of sphincter control is the main disability.

If the condition can be repaired by surgery, it is rated 100%. The 100% rating continues for two months after the surgery. The condition is then rated on any remaining symptoms.

For conditions that cannot be repaired by surgery:

A 100% rating is given if the prolapse cannot be put back in place.

A 50% rating is given if the prolapse can be put back in place by hand, and it occurs at times other than bowel movements, exertion, or the Valsalva maneuver (blowing air forcefully out the mouth while holding the nose).

A 30% rating is given if the prolapse can be put back in place by hand, and it occurs only with bowel movements, exertion, or the Valsalva maneuver.

A 10% rating is given if the prolapse resolves on its own.

The VA proposes getting rid of vague rating requirements and instead using measurable criteria that is known to reasonable reflect the level of functional impairment. These changes also add a 100% rating level to appropriately cover extremely severe cases.

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-Current- Code 7335: An anal fistula (or “fistula-in-ano”) is an abnormal passageway that connects the anus to other parts of the body or to an abnormal opening in the skin. This condition is rated as loss of sphincter control.

-Proposed- Code 7335: An anal fistula (or “fistula-in-ano”) is an abnormal passageway that connects the anus to other parts of the body or to an abnormal opening in the skin. This code also covers anorectal abscesses.

A 60% rating is given if there are three or more almost-constant fistulas with abscesses, drainage, and pain that do not respond to treatment.

A 40% rating is given if there are one to two fistulas with abscesses, drainage, and pain.

A 20% rating is given if there are two or more fistulas with drainage and pain.

A 10% rating is given if there is one fistula with drainage and pain.

Currently, this condition is rated under loss of sphincter control, but the VA argues that the main disability lies in pain, drainage, and abscesses, and so proposes a new rating system for this condition.

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-Current- Code 7336: Hemorrhoids are swollen veins inside or outside the body near the anus. They are created from a lot of pressure being used to pass feces and can be very painful. If the hemorrhoids cause constant bleeding that leads to significant blood loss and anemia, a decrease in the number of red blood cells, or if they cause Fissures, it is rated 20%. If there are blood clots inside the swollen veins, the swelling can’t go down, and there is a lot of Redundant Tissue, it is rated 10%. If they are only moderate with occasional bleeding, it is rated 0%.

-Proposed- Code 7336: Hemorrhoids are swollen veins inside or outside the body near the anus. They are created from a lot of pressure being used to pass feces and can be very painful.

A 20% rating is given for either internal or external hemorrhoids if there is regular bleeding that causes anemia.

A 20% rating is also given for internal hemorrhoids that constantly protrude from the anus and cause blood clots three or more times/year.

A 10% rating is given for internal hemorrhoids that constantly protrude from the anus and cause blood clots two or less times/year.

A 10% rating is also given for external hemorrhoids that cause blood clots three or more times/year.

The current ratings for hemorrhoids rate both internal and external the same, even though they have different symptoms. The VA proposes removing vague rating terms and creating different rating options for internal and external hemorrhoids.

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-Current- Code 7337: Pruritus ani is seriously itchy skin around the anus. This condition never develops by itself but is always a symptom of another condition. Because of that, the condition causing the itching is ratable, but the itching alone is not.

-Proposed- Code 7337: Pruritus ani is seriously itchy skin around the anus. If the itching results in tearing of the skin and bleeding, it is rated 10%. Otherwise, 0%.

Currently, this condition isn’t actually rated, only the underlying condition causing it. The VA argues that this results in the itching itself not being appropriately rated, and so proposes creating new rating criteria just for the itching.

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-Current- Code 7338: An inguinal hernia is a hernia in the hole in the Inguinal Canal that allows the organs in the abdomen fall into the inguinal canal.

If a surgery was performed to fix a large hernia, but it re-herniated and another surgery cannot be performed, it is rated 60%. If a surgery was performed to fix a small hernia, but it re-herniated, or if it cannot be fixed at all, it is rated 30%. If a surgery was performed to fix the hernia, it re-herniated, but it is treatable and can be supported by a belt, it is rated 10%. If a surgery was not performed, but it is treatable, or if it is small and no organs are pushing through the hole, it is rated 0%.

Note: There are two inguinal canals, and so both can herniate. If they do, and both qualify for a rating, then the most severe of the two is rated on the requirements above, and then 10% is added for the second hernia. Both do not get full ratings. So, if one is rated 30%, and the other can be rated 60%, only 10% is added to the 60% (highest) to equal a single 70% rating. The two conditions are covered by the single hernia condition rating.

Code 7339: A ventral hernia occurs when the abdominal organs push through a part of the abdominal wall. This condition is easily treated by surgery. If surgery has been performed, but there are still problems, the condition can then be rated on the following criteria.

If the hernia is really big, with a severe separation of the abdominal muscles, a destruction of the abdominal muscles over a large area, or with severe weakening of the muscles and tissues so that surgery would not be able to fix it, it is rated 100%. If the hernia is large and cannot be supported by a belt or brace, it is rated 40%. If it is small and cannot be supported by a belt or brace, or if the surgery worked and the wounds healed, but they are weak and need support by a belt or brace, it is rated 20%. If the surgery worked and the wounds healed well, it is rated 0%.

Code 7340: A femoral hernia occurs when the abdominal organs push through the femoral canal at the top of the thigh near the groin. This condition is rated as an inguinal hernia.

-Proposed- Code 7338: All abdominal hernias (except hiatal, code 7346) are rated under this code.

If the hernia can or has been successfully repaired and there are no symptoms, it is rated 0%.

All hernias that cannot be repaired are rated on the following:

A 100% rating is given if both of the following are present for 12 months or more:

· The hernia is 15cm or more

· There is pain with at least three of the following:

o Bending over

o Walking

o Climbing stairs

o Bathing/dressing/grooming/leaving home

A 60% rating is given if both of the following are present for 12 months or more:

· The hernia is 15cm or more

· There is pain with at least two of the following:

o Bending over

o Walking

o Climbing stairs

o Bathing/dressing/grooming/leaving home

A 30% rating is given if both of the following are present for 12 months or more:

· The hernia is between 3cm and 15cm

· There is pain with at least two of the following:

o Bending over

o Walking

o Climbing stairs

o Bathing/dressing/grooming/leaving home

A 20% rating is given if both of the following are present for 12 months or more:

· The hernia is between 3cm and 15cm

· There is pain with one of the following:

o Bending over

o Walking

o Climbing stairs

o Bathing/dressing/grooming/leaving home

A 10% rating is given if the hernia is less than 3cm for 12 months or more.

Note: There are two inguinal canals, and both can herniate. If they do, and both qualify for a rating, then the most severe of the two is rated on the requirements above, and then 10% is added for the second hernia, not to exceed 100%. Both do not get full ratings. So, if one is rated 30%, and the other can be rated 60%, only 10% is added to the 60% (highest) to equal a single 70% rating. The two conditions are both covered by the single rating.

Currently, the VA has four different codes for hernias. They argue, however, that all abdominal hernias, except hiatal, cause similar disabilities and so only need a single rating system. The VA proposes removing codes 7339 and 7340 and rating all abdominal hernias (except hiatal) under code 7338.

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Code 7342 for visceroptosis remains exactly the same.

Code 7343 for malignant cancer of the digestive system remains exactly the same.

Code 7344 for tumors of the digestive system remains exactly the same, except for adding specific instruction for lipoma, leiomyoma, colon polyps, and villous adenoma to be rated under this code when they affect the digestive system. They should already be rated under it anyway, but this instruction will ensure these conditions are correctly rated.

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-Current- Code 7345: Any chronic liver disease that doesn’t have Cirrhosis is rated under this code. This includes diseases like Hepatitis B, chronic active hepatitis, autoimmune hepatitis, hemochromatosis, drug-induced hepatitis, and others. Hepatitis C and bile duct disorders are not rated here.

Note: If there are two different conditions and one rates under this code and another rates as Hepatitis C under code 7354, then the symptoms caused by the condition rated under code 7354 cannot count towards another rating under this code.

If there are near-constant, completely disabling symptoms like fatigue, uneasiness, vomiting, anorexia, joint pain, and pain in the upper right abdomen, it is rated 100%.

If there is significant fatigue, uneasiness, anorexia with Significant Weight Loss or malnutrition, and swelling in the liver, or Incapacitating Episodes totaling 6 weeks or more in the past year that include symptoms like fatigue, uneasiness, nausea, vomiting, anorexia, joint pain and pain in the upper right abdomen, it is rated 60%.

If there is significant fatigue, uneasiness, anorexia with weight loss and swelling in the liver, or if there are incapacitating episodes totaling 4 to 6 weeks in the past year that include symptoms like fatigue, uneasiness, nausea, vomiting, anorexia, joint pain, and pain in the upper right abdomen, it is rated 40%.

If there is significant fatigue, uneasiness, and anorexia (without weight loss) that requires either a special diet or constant medication, or if there are incapacitating episodes totaling 2 to 4 weeks in the past year that include symptoms like fatigue, uneasiness, nausea, vomiting, anorexia, joint pain, and pain in the upper right abdomen, it is rated 20%.

If there is occasional fatigue, uneasiness, and anorexia, or if there are incapacitating episodes totaling 1 to 2 weeks in the past year that include symptoms like fatigue, uneasiness, nausea, vomiting, anorexia, joint pain, and pain in the upper right abdomen, it is rated 10%.

If the condition does not have any symptoms, it is rated 0%.

-Proposed- Code 7345: Any chronic liver disease that doesn’t have Cirrhosis is rated under this code. This includes diseases like Hepatitis B, primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune liver disease, Wilson’s disease, Alpha-1-antitrypsin deficiency, hemochromatosis, non-alcoholic steatohepatitis, drug-induced hepatitis, and more.

Note: Any condition caused by the liver disease can be rated separately as long as a single symptom is not rated more than once (see the Pyramiding Principle.)

A 100% rating is given if the condition is continuing to get worse and it requires both antiviral and immunomodulatory drugs administered through an IV. The 100% rating continues for 6 months following the end of treatment. It is then re-evaluated and rerated on any remaining symptoms. If the condition needs antiviral and immunomodulatory treatment, but it can’t be given because of other medical concerns, then the condition is rated under code 7312.

A 60% rating is given if the condition is continuing to get worse, it requires continuous medication, there is substantial weight loss, and there are two or more of the following:

· Daily fatigue

· Malaise

· Anorexia

· Enlarged liver

· Itchy skin

· Stiffness in the joints

A 40% rating is given if the condition is continuing to get worse, it requires continuous medication, there is minor weight loss, and there are two or more of the following:

· Daily fatigue

· Malaise

· Anorexia

· Enlarged liver

· Itchy skin

· Stiffness in the joints

A 20% rating is given if there is one or more of the following:

· Occasional fatigue

· Malaise

· Anorexia

· Enlarged liver

· Itchy skin

A 0% rating is given if there are no symptoms.

The VA is proposing these changes to get rid of vague terms and provide more clinically-measurable rating options for liver diseases based on updated medical understandings and treatments. With more specific rating criteria, the VA argues that having a 10% rating is no longer pertinent since there are clear distinctions between the remaining rating levels.

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-Current- Code 7346: A hiatal hernia is a hernia in the Diaphragm that allows the organs in the abdomen to move up into the chest cavity.

If the hernia causes pain, vomiting, significant weight loss, blood in the vomit or feces, and anemia, or if other symptoms cause a serious overall health disability, it is rated 60%. If there are regular episodes of pain in the upper abdomen, trouble swallowing, heartburn, the return of food into the back of the throat/mouth, and pain in the upper arm or shoulder, it is rated 30%. If two or more of the previous symptoms are present, but are not as severe, it is rated 10%.

-Proposed- Code 7346: A hiatal hernia (including a paraesophageal hernia) is a hernia in the Diaphragm that allows the organs in the abdomen to move up into the chest cavity. It is rated under code 7203.

The VA is proposing to remove the ratings for a hiatal hernia and instead rate it under code 7203 for stricture of the esophagus. Hiatal hernias cause very similar symptoms to esophageal strictures, and so the VA feels that they are appropriately rated by these criteria.

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-Current- Code 7347: Pancreatitis is the swelling of the pancreas that occurs because the enzymes it produces become active while still in the pancreas. If diabetes and pancreatitis are both present, both cannot be rated. Rate only the one that gives the highest rating. If the whole or part of the pancreas is surgically removed, then rate any continuing symptoms on the following ratings, with the minimum rating of 30%.

Ratings: If there are seriously disabling attacks of stomach pain with very few pain-free periods, significant amounts of fat in the feces, the inability of the small intestine to absorb the necessary nutrients, diarrhea, and severe malnutrition, it is rated 100%.

If there are frequent attacks of disabling stomach pain, weight loss (lower than the average weight weighed over the last year), and other symptoms like diarrhea or significant amounts of fat in the feces, it is rated 60%.

If there are at least 4 to 7 attacks of disabling stomach pain each year, it is rated 30%.

If there is at least 1 attack of disabling stomach pain each year, it is rated 10%.

-Proposed- Code 7347: Chronic pancreatitis occurs when the pancreas is permanently damaged by the swelling of the pancreas (acute pancreatitis) that occurs because the enzymes it produces become active while still in the pancreas.

Note: If pancreatic insufficiency causes diabetes, it is rated separately under code 7913.

To qualify for a rating, proper medical testing must confirm that the pain is located in the stomach or mid-back and definitely the result of the pancreatitis.

A 100% rating is given if there are daily episodes of pain and all of the following:

· Three or more hospitalizations each year

· Pain management by a physician

· Inability to properly digest nutrients

· Inability to properly absorb nutrients

· Required dietary restriction

· Required pancreatic enzyme supplementation

A 60% rating is given if there are three or more episodes of pain each year and at least one hospitalization each year to treat complications of either the pain or of Enteral Nutrition.

A 30% rating is given if there is one or more episodes of pain each year that requires ongoing treatment for the pain, digestive problems, or for complications (like cysts, intestinal obstructions, etc.).

The VA is proposing to specify that these rating options are for chronic pancreatitis since the acute condition is easily and successfully treated in most cases. It is only in cases of chronic pancreatitis that a long-term disability is established. For the ratings, the VA proposes to update them to reflect the more common disabling symptoms seen in relation to current medical treatments.

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-Current- Code 7348: A vagotomy is a surgical procedure where the vagus nerve, which stimulates the production of stomach acid, is cut in order to reduce the amount of acid produced in the stomach. To qualify for a rating, the surgery must have been performed with either a Gastroenterostomy or a Pyloroplasty as well.

After the surgery, if there continues to be significant problems with food passing from the stomach to the small intestine, it is rated 40%.

If there is a definite diagnosis of Alkaline Gastritis or regular diarrhea, it is rated 30%.

If the surgery was not successful in decreasing the amount of acid production and an ulcer forms or reforms, it is rated 20%.

If the surgery was successful, but an ulcer reforms anyway, it is then rated under code 730 with the minimum rating of 20%.

-Proposed- Code 7348: A vagotomy is a surgical procedure where the vagus nerve, which stimulates the production of stomach acid, is cut either to reduce the amount of acid produced in the stomach or following a lung transplant. To qualify for a rating, the surgery must have been performed with either a Gastroenterostomy or a Pyloroplasty as well.

A 40% rating is given if there continues to be significant problems with food passing from the stomach to the small intestine.

A 30% rating is given if Alkaline Gastritis is diagnosed or if there is regular diarrhea.

A 20% rating is given if the surgery was not successful in decreasing the amount of acid production.

If the surgery was successful, but an ulcer reforms anyway, it is rated under code 7304 with the minimum rating of 20%.

All other side effects not covered by a rating under this code are rated under code 7303.

Only a few minor changes are being proposed for this code. The first is to remove the need for recurrent ulcers for the 20% rating since ulcers aren’t present in all cases that require vagotomies. The other substantial change is the instruction to rate side effects under code 7303.

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-NEW Proposed Code- Code 7350: A liver abscess is a pus-filled infection in the liver.

A 100% rating is given for the first 6 months following the date of diagnosis. It is then re-evaluated and rerated based on any remaining symptoms under the appropriate code.

The VA proposes adding a new code to cover all liver abscesses, regardless of the cause, in order to ensure that all are consistently rated and a sufficient rating given for an active infection.

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-Current- Code 7351: If a liver transplant is performed, it is rated 100%. This 100% rating continues for 1 year following the date of hospital admission for the surgery. The condition is then re-evaluated, and the main residual symptom or complication is rated. The minimum rating for a liver transplant is 30%.

-Proposed- Code 7351: If a liver transplant is performed, it is rated 100%. This 100% rating continues for 1 year following the date of hospital admission for the surgery. The condition is then re-evaluated and rerated on any remaining symptoms or complications.

The minimum rating for a liver transplant is 30%. If the condition is waiting for a re-transplant, the minimum rating is 60%.

The only significant proposed change to this code is to add a minimum 60% rating if a new transplant is needed.

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-NEW Proposed Code- Code 7352: If a pancreas transplant is performed, it is rated 100%. This 100% rating continues for 1 year following the date of hospital admission for the surgery. The condition is then re-evaluated and rerated on any remaining symptoms or complications. The minimum rating for a pancreas transplant is 30%.

The VA proposes adding a new code to cover pancreas transplant, a surgery that wasn’t performed when this section was first published.

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-Current- Code 7354: Hepatitis C or any hepatitis that is not A or B can be rated under this code. Hepatitis C is an infection in the liver that most often does not show any symptoms. A worse case of hepatitis C can, however, lead to cirrhosis, liver cancer, and liver failure. For this condition to qualify for a rating, its presence must be proved by a serologic test.

Note: If there are two different conditions and one rates under this code and another rates under, say 7345, then the symptoms caused the by condition rated under this code cannot count towards another rating under code 7345.

If there is near-constant, completely disabling symptoms like fatigue, uneasiness, vomiting, anorexia, joint pain, and pain in the upper right abdomen, it is rated 100%. If there is significant fatigue, uneasiness, anorexia with Significant Weight Loss or malnutrition, and swelling in the liver, or Incapacitating Episodes totaling 6 weeks or more in the past year that include symptoms like fatigue, uneasiness, nausea, vomiting, anorexia, joint pain and pain in the upper right abdomen, it is rated 60%.

If there is significant fatigue, uneasiness, anorexia with weight loss, and swelling in the liver, or if there are incapacitating episodes totaling 4 to 6 weeks in the past year that include symptoms like fatigue, uneasiness, nausea, vomiting, anorexia, joint pain, and pain in the upper right abdomen, it is rated 40%.

If the condition does not have any symptoms, it is rated 0%.

-Proposed- Code 7354: Hepatitis C or any hepatitis that is not A or B can be rated under this code. Hepatitis C is an infection in the liver that most often does not show any symptoms. A severe case of hepatitis C can, however, lead to cirrhosis, liver cancer, and liver failure. For this condition to qualify for a rating, it must be diagnosed by a serologic test. It is rated under code 7345.

Hepatitis C is already rated on the same criteria as chronic liver disease, code 7345, so the VA proposes simplifying things and simply instructing it to be rated under code 7345 instead of listing the ratings again under this code.

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-NEW Proposed Code- Code 7355: Celiac disease is a condition where the immune system reacts to eating gluten. In order to be rated, the condition must be officially diagnosed using a serum antibody test or endoscopy with biopsy.

Most cases of Celiac disease can be fully managed by dietary changes, however, some cases do not properly respond to these changes. These cases can lead to Malabsorption Syndrome (the inability of the body to properly absorb nutrients).

Note: If the main symptom is the inability to properly absorb nutrients, then it is either rated under this code or under code 7328, whichever gives a higher rating.

An 80% rating is given if there is Malabsorption Syndrome and all of the following:

· Weakness that interferes with bathing, dressing, eating, using the restroom, etc.

· Weight loss with wasting and nutritional deficiencies

· Systemic manifestations (weakness, fatigue, dermatitis, swollen lymph nodes, hypocalcemia, low vitamin levels, etc.)

· Anemia

· Lactase deficiency or pancreatic insufficiency resulting in episodes of stomach pain and diarrhea

A 50% rating is given if there is Malabsorption Syndrome and all of the following:

· Chronic diarrhea controlled by prescribed dietary modification

· Nutritional deficiencies caused by lactase deficiency and pancreatic insufficiency

· Systemic manifestations (weakness, fatigue, dermatitis, swollen lymph nodes, hypocalcemia, low vitamin levels, atrophy of intestinal lining, etc.)

A 30% rating is given if there is Malabsorption Syndrome and Chronic diarrhea controlled by prescribed dietary modification.

The VA proposes adding a new code to cover Celiac disease, a condition not currently appropriately covered by any existing code. This will enable consistent, fair ratings for Celiac disease.

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-NEW Proposed Code- Code 7356: Gastrointestinal dysmotility syndrome is a term that covers a wide range of conditions where the esophagus, stomach, and/or intestines have difficulty moving food throughout the digestive tract with no known reason. It is most common among Gulf War Veterans. A condition can only be rated under this code if it is not already covered under code 7319.

An 80% rating is given if there is complete dependence on Total Parenteral Nutrition or continuous Enteral Nutrition.

A 50% rating is given if it requires intermittent Enteral Nutrition and repeated visits to the ER for intestinal obstruction or regurgitation caused by stomach pain, nausea, vomiting, or poor gastric emptying.

A 30% rating is given if the condition requires prescribed dietary modification and outpatient care for symptoms like stomach pain, physical stomach bloating, feeling bloated, nausea, vomiting, regurgitation, constipation, diarrhea, etc.

A 10% rating is given if there is regular stomach pain, physical stomach bloating, and feeling bloated.

The VA proposes adding a new code to cover all motility disorders not properly covered by other ratings and that have no known cause. This will especially help Gulf War Vets get fair ratings for their digestive motility conditions caused by their Gulf War service.

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-NEW Proposed Code- Code 7357: A pancreatectomy is the full or partial removal of the pancreas which can result in Post-pancreatectomy Syndrome. This condition is rated under one of the following codes: 7347, 7303, 7328, 7319, 7326, or 7913. Choose the code that gives the highest rating for its symptoms, with a minimum rating of 30%.

The VA proposes adding a new code to cover residuals after a pancreatectomy. While the code instructs rating under the code that gives the highest rating, giving it its own code will help the VA track cases in the veteran population and standardize rating options.