[Federal Register Volume 76, Number 128 (Tuesday, July 5, 2011)]
[Proposed Rules]
[Pages 39160-39184]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-15698]



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Vol. 76

Tuesday,

No. 128

July 5, 2011

Part II





Department of Veteran Affairs





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38 CFR Part 4





Schedule for Rating Disabilities; The Digestive System; Proposed Rule

  Federal Register / Vol. 76 , No. 128 / Tuesday, July 5, 2011 / 
Proposed Rules  

[[Page 39160]]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AN12


Schedule for Rating Disabilities; The Digestive System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the 
portion of the Schedule for Rating Disabilities that addresses the 
Digestive System. The purpose of this change is to incorporate medical 
advances that have occurred since the last review, insert current 
medical terminology, and provide clear criteria.

DATES: Comments must be received by VA on or before September 6, 2011.

ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand-delivery to the Director, 
Regulations Management (02REG), Department of Veterans Affairs, 810 
Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202) 
273-9026. Comments should indicate that they are submitted in response 
to RIN 2900-AN12-Schedule for Rating Disabilities; The Digestive 
System. Copies of comments received will be available for public 
inspection in the Office of Regulation Policy and Management, Room 
1063B, between the hours of 8 a.m. and 4:30 p.m. Monday through Friday 
(except holidays). Please call (202) 461-4902 for an appointment. (This 
is not a toll-free number.) In addition, during the comment period, 
comments may be viewed online through the Federal Docket Management 
System at http://www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Thomas J. Kniffen, Chief, Regulations 
Staff (211D), Compensation and Pension Service, Veterans Benefits 
Administration, Department of Veterans Affairs, 810 Vermont Avenue, 
NW., Washington, DC 20420, (202) 461-9725. (This is not a toll-free 
number.)

SUPPLEMENTARY INFORMATION: VA published an advance notice of proposed 
rulemaking in the Federal Register of May 2, 1991 (56 FR 20168), 
advising the public of our intent to revise and update the portion of 
the Schedule for Rating Disabilities (the rating schedule) that 
addresses the digestive system as well as to solicit and obtain 
comments and suggestions from interest groups and the general public. 
By revising the rating schedule, we aim to eliminate ambiguities, 
include medical conditions not currently in the rating schedule, and 
implement current medical criteria and terminology that reflect recent 
medical advances.

Comments in Response To Advance Notice of Proposed Rulemaking

    In response to the advance notice of proposed rulemaking, we 
received comments from the American Legion and from several VA 
employees. One commenter suggested that we add to the rating schedule 
Crohn's disease; esophageal spasm (with its own evaluation criteria); 
hepatitis A, B, and C; chronic inflammation of the liver and its 
residuals; and malabsorption due to pancreatic disease. We propose to 
address each of these conditions in this revision, except for hepatitis 
and chronic inflammation of the liver, which were addressed in a 
separate rulemaking on liver disabilities (66 FR 29486, May 31, 2001).
    The same commenter suggested we include reflux esophagitis with 
hiatal hernia, with the criteria taking into account a measurement of 
reflux. For esophageal abnormalities, reflux measurement (manometry), 
barium swallows, and esophagoscopy provide information about 
physiological and anatomical abnormalities, and may be useful for 
diagnosis and prognosis, for determining response to therapy, and to 
prepare for surgery. They are less useful, however, in assessing the 
level of disability than the severity of symptoms, the impact of the 
condition on the nutritional status of the patient, and the potential 
for remediation (``Disability Evaluation'' 379 (Stephen L. Demeter, 
M.D., Gunnar B.J. Anderson, M.D., and George M. Smith, M.D., 1996) and 
The Merck Manual 113 (18th ed. 2006)). While we propose to address 
reflux esophagitis in this revision, as discussed further below, we do 
not propose to use a measurement of reflux for evaluation.
    A second commenter suggested we add Crohn's disease and also revise 
the criteria for hemorrhoids. We propose to do both.
    One commenter suggested that we evaluate gastrectomy and vagotomy-
pyloroplasty under the same criteria. The major postoperative problem 
related to gastrectomy is dumping syndrome, which is the common term 
that refers to the group of symptoms that may occur following various 
types of surgery for ulcer disease. Many problems may be associated 
with vagotomy-pyloroplasty, of which dumping syndrome is only one. We 
therefore propose to retain separate evaluation criteria for these 
conditions, as discussed in more detail below.
    The same commenter suggested that we delete diagnostic codes 7201 
(lips, injuries of), 7205 (esophagus, diverticulum of, acquired), 7306 
(marginal ulcer), 7309 (stomach, stenosis of), 7310 (stomach, injury 
of, residuals), 7315 (chronic cholelithiasis), 7316 (chronic 
cholangitis), 7324 (distomiasis, intestinal or hepatic), and 7342 
(visceroptosis) because they are rare.
    We propose to remove diagnostic code 7342 (visceroptosis) because 
visceroptosis is an obsolete diagnosis, as discussed further below. 
However, we propose to retain all of the other diagnostic codes 
mentioned by the commenter, although some in a revised form, since some 
of them, such as diagnostic code 7315 (cholelithiasis), represent 
common digestive diseases, and others, such as those for injuries of 
the lips or stomach, may be the only appropriate codes under which to 
address injuries, including combat wounds, to those parts of the body. 
They may therefore be useful to VA for statistical purposes, as well as 
for rating purposes.
    Another commenter suggested we remove diagnostic code 7201 (lips, 
injuries of); add esophagitis, duodenitis, and Crohn's disease; provide 
a diagnostic code for total gastrectomy; add a 10-percent evaluation 
level for cirrhosis; provide evaluation criteria for ileostomy and 
colostomy; and provide objective evaluation criteria for pancreatitis. 
We have already discussed injuries of the lips, which we propose to 
retain. We otherwise propose to follow all of these suggestions, with 
two exceptions. First, we do not propose to add a diagnostic code for 
total gastrectomy, because that condition can be appropriately 
evaluated under an existing diagnostic code (7308, Postgastrectomy 
syndromes). Second, we have already added a 10-percent evaluation level 
for cirrhosis in the separate rulemaking that addressed disabilities of 
the liver (66 FR 29486, May 31, 2001), so there is no need for further 
action in this proposed rule based on that comment. This commenter also 
suggested we remove diagnostic codes 7342 (visceroptosis) and 7337 
(pruritus ani) and that we delete the word ``infectious'' from 
``infectious hepatitis.'' We also propose to remove diagnostic codes 
7342 and 7337. The suggested change concerning hepatitis was made in 
the separate rulemaking for liver disabilities, so there is no need for 
further action in this proposed rule.

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Outside Consultants

    In addition to publishing an advance notice of proposed rulemaking, 
VA contracted with an outside consulting firm for the purpose of 
gathering suggestions for changes in the rating schedule to help 
fulfill the goals of revising and updating the medical criteria. This 
proposed amendment includes many of their suggestions. Since one of the 
goals of the rating schedule revision is to eliminate ambiguities, we 
did not follow some of our consultants' recommendations that are based, 
at least, in part, on subjective or indefinite language when more 
objective terminology could be used. Furthermore, each group of 
consultants reviewed only one portion or body system of the rating 
schedule, and we had to assess the feasibility of their recommendations 
in light of the entire rating schedule, in order to assure internal 
consistency. Relevant recommendations from our consultants are 
discussed below.

Section 4.110

    Current Sec.  4.110, ``Ulcers,'' explains that ``the term `peptic 
ulcer' is not sufficiently specific for rating purposes'' because there 
are ``manifest differences'' between ulcers of the stomach or duodenum 
as compared to those at an anastomotic stoma, and that, therefore, the 
location of an ulcer should be identified in order to evaluate it. This 
material is unnecessary, since there are separate diagnostic codes for 
ulcers of the stomach, duodenum, and gastrojejunal area (or anastomotic 
stoma), and the rating schedule therefore makes it clear that the site 
of an ulcer must be identified in order to assign the correct 
diagnostic code. Furthermore, this section establishes no procedures 
that raters must follow in evaluating ulcer disease. We therefore 
propose to remove the material currently in Sec.  4.110, retitle this 
section ``Dyspepsia,'' and provide in it a definition of the term 
``dyspepsia'' for purposes of evaluating conditions in Sec.  4.114. We 
propose that Sec.  4.110 would define dyspepsia as any combination of 
the following symptoms: Gnawing or burning epigastric or substernal 
pain that may be relieved by food (especially milk) or antacids, 
nausea, vomiting, anorexia (lack or loss of appetite), abdominal 
bloating, and belching. It would also state that when there is 
obstruction of the outlet of the stomach (gastric outlet obstruction), 
dyspepsia may also include symptoms of gastroesophageal reflux (flow of 
stomach contents back into the esophagus), borborygmi (audible rumbling 
bowel sounds), crampy pain, and obstipation (severe constipation).

Section 4.111

    Current Sec.  4.111, ``Postgastrectomy syndromes,'' discusses 
dumping syndrome, a condition which is relevant only to diagnostic code 
7308, ``postgastrectomy syndromes,'' and we propose to list the 
symptoms of dumping syndrome in a note under that diagnostic code. We 
therefore propose to remove Sec.  4.111.

Section 4.112

    Current Sec.  4.112, ``Weight loss,'' defines ``substantial weight 
loss,'' ``minor weight loss,'' ``inability to gain weight,'' and 
``baseline weight,'' for purposes of evaluating conditions in Sec.  
4.114. Some of the revisions of conditions in Sec.  4.114 that we are 
proposing have evaluation criteria that are based in part on 
malnutrition, and there is no universally accepted definition of 
malnutrition. We, therefore, propose to provide a definition of 
malnutrition for purposes of evaluating conditions in Sec.  4.114 by 
expanding the title of Sec.  4.112 to ``Weight loss and malnutrition'' 
and adding the following definition: `` `malnutrition' means a 
deficiency state resulting from insufficient intake of one or multiple 
essential nutrients or the inability of the body to absorb, utilize, or 
retain such nutrients. It is characterized by failure of the body to 
maintain normal organ functions and healthy tissues.''

Section 4.113

    Current Sec.  4.113, ``Coexisting abdominal conditions,'' states 
that there are diseases of the digestive system that produce a common 
disability picture with similar symptoms and which should therefore not 
be rated separately, as this would be a violation of 38 CFR 4.14, 
``Avoidance of pyramiding'' (which states that the evaluation of the 
same disability under various diagnoses is to be avoided). Current 
Sec.  4.114, in an introductory paragraph, lists specific diagnostic 
codes that cannot be combined, and directs that a single evaluation 
``be assigned under the diagnostic code that reflects the predominant 
disability picture, with elevation to the next higher evaluation where 
the severity of the overall disability warrants such evaluation.'' In 
order to provide clear guidance about evaluation when there are two or 
more coexisting digestive conditions, we propose to revise the material 
in Sec. Sec.  4.113 and 4.114 related to this subject and place the 
revised directions in Sec.  4.113.
    We propose to direct the rater to separately evaluate two or more 
conditions in Sec.  4.114 only if the signs and symptoms attributed to 
each are separable, and if they are not separable, to assign a single 
evaluation under the diagnostic code that best allows evaluation of the 
overall functional impairment resulting from both conditions. With 
these instructions, the list of conditions that may not be combined, 
given in current Sec.  4.114, would be unnecessary, and we propose to 
remove it. This revision would provide a fair and equitable method of 
evaluation, and is not contrary to Sec.  4.14. In addition, it would 
remove the somewhat unclear direction to assign a diagnostic code that 
reflects the predominant disability and elevate to the next higher 
evaluation level ``where the severity of the overall disability 
warrants such elevation,'' a direction that could be interpreted 
differently by different individuals. We also propose to change the 
title of Sec.  4.113 to ``Evaluation of coexisting digestive 
conditions,'' since not all disabilities in this body system are 
abdominal, as the current title of Sec.  4.113 implies.

Section 4.114 Schedule of Ratings-Digestive System

Mouth injuries, Lip injuries, Tongue Injuries (Including Tongue Loss), 
Esophageal Stricture, Achalasia (Cardiospasm) and Other Motor Disorders 
of the Esophagus, and Esophageal Diverticula (Diagnostic Codes 7200-
7205)

    The current rating schedule directs that injuries of the mouth 
(diagnostic code 7200) be evaluated on the basis of disfigurement and 
impairment of masticatory function, and injuries of the lips 
(diagnostic code 7201) on the basis of disfigurement of the face. Both 
mouth and lip injuries are therefore evaluated using criteria under 
other diagnostic codes. Loss of whole or part of the tongue (diagnostic 
code 7202) is currently evaluated at 100 percent if there is inability 
to communicate by speech, at 60 percent if there is loss of one-half or 
more of the tongue, and at 30 percent if there is marked speech 
impairment. Findings in these three conditions sometimes overlap, 
according to our consultants, with the major problems being (1) 
Difficulty with mastication (chewing) or swallowing, causing a 
restriction of diet; (2) difficulty with speech; (3) loss of part of 
the tongue; and (4) disfigurement. We therefore propose to provide a 
general rating formula for the evaluation of residuals of mouth 
injuries, lip injuries,

[[Page 39162]]

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

[[Page 39163]]

rating schedule, for the sake of promoting consistent evaluations. Our 
consultants also included the nebulous phrase ``interfering with normal 
daily functioning,'' which could be subject to different 
interpretations by different people, and we do not propose to use this 
language. However, the criteria are otherwise substantially the same as 
those our consultants recommended.

Salivary Gland Disease (Diagnostic Code 7207)

    Since there is no current diagnostic code under which salivary 
gland disease can be appropriately evaluated, and it is a common enough 
disability in veterans to require evaluation, we propose to add 
diagnostic code 7207, ``Salivary gland (parotid, submandibular, 
sublingual) disease other than neoplasm.'' We propose that there be 20-
, 10-, and zero-percent evaluation levels, based on the presence of 
xerostomia (dry mouth) and its effects, chronic inflammation or 
swelling of a salivary gland, salivary gland calculi or stricture, 
increase in dental caries, and weight loss, because these are the major 
impairments that may result from salivary gland disease (``Textbook of 
Gastroenterology'' 225 (Tadataka Yamada, M.D., ed., 1991)).
    We propose a 20-percent evaluation for xerostomia (dry mouth) with 
altered sensation of taste and difficulty with lubrication and 
mastication of food resulting in either weight loss or increase in 
dental caries; a 10-percent evaluation for xerostomia with altered 
sensation of taste and difficulty with lubrication and mastication of 
food, but without weight loss or increase in dental caries; chronic 
inflammation of a salivary gland with pain and swelling on eating; one 
or more salivary calculi; or a salivary gland stricture. We propose a 
zero-percent evaluation for either xerostomia without difficulty in 
mastication of food, or painless swelling of the salivary gland. We are 
proposing a zero-percent evaluation level in order to make it clear 
that these findings warrant a zero-, rather than a ten-percent 
evaluation when it might otherwise be unclear to the rater.
    We also propose to provide note (1) directing that facial nerve 
(cranial nerve VII) impairment, which may result from parotid gland 
disease or its treatment, be evaluated under diagnostic code 8207 
(cranial nerve VII) and that any disfigurement due to facial swelling 
be evaluated under diagnostic code (Burn scar(s) of the head, face, or 
neck; scar(s) of the head, face, or neck due to other causes; or other 
disfigurement of the head, face, or neck). We propose to add note (2) 
to explain what Sjogren's syndrome is and how it should be evaluated. 
It is an autoimmune disorder that causes xerostomia (dry mouth) and 
keratoconjunctivitis sicca (dry eyes) and may affect other parts of the 
body. The note directs that the effects of xerostomia (dry mouth) due 
to Sjogren's syndrome be evaluated under diagnostic code 7207, 
keratoconjunctivitis sicca under the portion of the rating schedule 
that addresses Organs of Special Sense, and other effects of the 
syndrome, if any, on other body parts under appropriate diagnostic 
codes in other sections of the rating schedule.

Peritoneal Adhesions (Diagnostic Code 7301)

    Peritoneal adhesions, diagnostic code 7301, are currently evaluated 
at levels of 50, 30, 10, or zero percent. A 50-percent evaluation is 
assigned if adhesions are severe, with ``definite partial obstruction 
shown by X-ray, with frequent and prolonged episodes of severe colic 
distention, nausea or vomiting, following severe peritonitis, ruptured 
appendix, perforated ulcer, or operation with drainage.'' A 30-percent 
evaluation is assigned if adhesions are moderately severe, with 
``partial obstruction manifested by delayed motility of barium meal and 
less frequent and less prolonged episodes of pain.'' A 10-percent 
evaluation is assigned if adhesions are moderate, with ``pulling pain 
on attempting work or aggravated by movements of the body, or 
occasional episodes of colic pain, nausea, constipation (perhaps 
alternating with diarrhea) or abdominal distention.'' A zero-percent 
evaluation is assigned if adhesions are ``mild.'' Subjective adjectives 
such as ``mild,'' ``moderate,'' ``moderately severe,'' and ``severe'' 
are used at each level.
    We propose to provide evaluation levels of 60, 30, or 10 percent 
for peritoneal adhesions, based primarily on the number of episodes of 
partial intestinal obstruction with typical symptoms, which may 
include, but are not limited to colicky abdominal pain, abdominal 
distention, borborygmi (audible rumbling bowel sounds), nausea, 
vomiting, and obstipation (severe constipation) (Yamada, 719). X-ray 
confirmation of a partial bowel obstruction would be required for any 
level of evaluation.
    We propose a 60-percent evaluation for six or more episodes per 
year of partial obstruction of the bowel (confirmed by X-ray), with 
typical signs and symptoms (which may include, but are not limited to 
colicky abdominal pain, abdominal distention, borborygmi (audible 
rumbling bowel sounds), nausea, vomiting, and obstipation) (severe 
constipation)); a 30-percent evaluation for three to five episodes per 
year of partial obstruction of the bowel, with typical signs and 
symptoms; and a 10-percent evaluation for either of the following: One 
or two episodes per year of partial obstruction of the bowel, with 
typical signs and symptoms, or, in the absence of such episodes, 
pulling pain on body movement, if not attributable to another 
condition.
    These criteria are in general agreement with those recommended by 
our consultants, but they exclude subjective terms such as 
``frequent,'' ``occasional,'' and ``severe'' that the consultants 
suggested, in favor of more objective criteria in order to promote 
consistent evaluations.
    A current note following diagnostic code 7301 states that ratings 
for adhesions will be considered when there is a history of operative 
or other traumatic or infectious (intraabdominal) process and at least 
two of the following: Disturbance of motility, actual partial 
obstruction, reflex disturbances, or presence of pain. We propose to 
revise this note to state that evaluation under diagnostic code 7301 
requires a history of abdominal or pelvic surgery, infection, 
irradiation, trauma, or other known etiology for peritoneal adhesions. 
We propose to add a second note listing the typical signs and symptoms 
of partial bowel obstruction, for purposes of evaluation under 
diagnostic code 7301. This would simplify the evaluation criteria by 
eliminating the need to repeat the list of symptoms at each level. Our 
consultants recommended that we provide a note similar to the current 
note, with both causes and symptoms of adhesions listed, and we have 
basically done this, but divided the material into two notes, for the 
sake of clarity.

General Rating Formula for Ulcer Disease (Diagnostic Codes 7304-7306)

    There are currently three diagnostic codes for ulcers: diagnostic 
code 7304 for gastric ulcers, diagnostic code 7305 for duodenal ulcers, 
and diagnostic code 7306 for marginal (gastrojejunal) ulcers. No 
specific evaluation criteria are provided for gastric ulcers, but they 
are ordinarily rated under the criteria for duodenal ulcers. Duodenal 
ulcers are currently evaluated at levels of 60, 40, 20, or 10 percent. 
A 60-percent evaluation is assigned if the condition is severe, with 
pain only partially relieved by ulcer therapy, and there is periodic 
vomiting, recurrent hematemesis or melena, with manifestations of 
anemia and weight loss, productive of definite impairment of health. A 
40-percent evaluation is assigned if the condition is moderately 
severe, meaning that it is

[[Page 39164]]

less than severe but with impairment of health manifested by anemia and 
weight loss, or that there are recurrent incapacitating episodes 
averaging 10 days or more in duration at least four or more times a 
year. A 20-percent evaluation is assigned if the condition is moderate, 
with recurring episodes of severe symptoms two or three times a year 
averaging 10 days in duration, or with continuous moderate 
manifestations. A 10-percent evaluation is assigned if the condition is 
mild, with recurring symptoms once or twice yearly.
    Marginal ulcers are currently evaluated under a separate set of 
criteria that are similar to those for duodenal ulcer, except that 
there is also a 100-percent evaluation level, to be assigned if the 
condition is pronounced, with periodic or continuous pain unrelieved by 
standard ulcer therapy with periodic vomiting, recurring melena or 
hematemesis, and weight loss, and the condition is totally 
incapacitating. A 60-percent evaluation is assigned if the condition is 
severe, with symptoms of the same type as pronounced but less 
pronounced and less continuous, with definite impairment of health. A 
40-percent evaluation is assigned if the condition is moderately 
severe, with intercurrent episodes of abdominal pain at least once a 
month partially or completely relieved by ulcer therapy, or there are 
mild and transient episodes of vomiting or melena. A 20-percent 
evaluation is assigned if the condition is moderate, with episodes of 
recurring symptoms several times a year. A 10-percent evaluation is 
assigned if the condition is mild, with brief episodes of recurring 
symptoms once or twice yearly. Both sets of criteria for rating ulcer 
disease use subjective adjectives such as ``mild,'' ``moderate,'' and 
``pronounced'' throughout the formulas.
    Our consultants pointed out that while ulcers may vary in location, 
they produce the same array of symptoms, and do not differ in 
functional impairment. They suggested that all types of ulcers be 
evaluated under the same criteria: the presence of symptoms and their 
response or lack of response to treatment, the extent of incapacitating 
or recurring episodes, and whether there is recurrent hematemesis 
(vomiting blood) or melena, anemia, or weight loss. We propose to 
adopt, with some modifications, their recommendations regarding bases 
of evaluations and to evaluate all types of ulcer disease under the 
same criteria. We propose to provide a single rating formula for 
gastric ulcer (diagnostic code 7304), duodenal ulcer (diagnostic code 
7305), and marginal (gastrojejunal) ulcer (diagnostic code 7306), based 
on the recommended criteria. We also propose to change the title of 
diagnostic code 7305 to ``duodenal ulcer or duodenitis'' in order to 
include duodenitis under this code, because these conditions commonly 
occur together and result in similar findings. We propose to provide 
evaluation levels of 100, 60, 30, and 10 percent. Our consultants 
suggested 60 percent as the highest level of evaluation, but, because 
our experience has shown that a number of veterans are totally disabled 
by severe ulcer disease, we propose to add a 100-percent level. These 
levels also differ from the current schedule by substituting a 30-
percent level for the current 20- and 40-percent levels. This change 
will provide a clearer distinction between the 10-percent level and the 
next higher level (which we propose to be 30 percent instead of 20 
percent), a factor that will promote more consistent evaluations, and 
will still be sufficient to accommodate the range of severity of ulcer 
disease.
    We propose a 100-percent evaluation for either substantial weight 
loss, malnutrition, and anemia due to gastrointestinal bleeding; or for 
hospitalization three or more times per year for vomiting, refractory 
pain, gastrointestinal bleeding, perforation, obstruction, or 
penetration to liver, pancreas, or colon. We propose a 60-percent 
evaluation for either periodic or constant dyspepsia with substantial 
weight loss and anemia due to ulcer disease; or for hospitalization two 
times per year for vomiting, refractory pain, gastrointestinal 
bleeding, perforation, obstruction, or penetration to liver, pancreas, 
or colon. We propose a 30-percent evaluation for either periodic or 
constant dyspepsia with at least minor weight loss; or for 
hospitalization once per year for vomiting, refractory pain, 
gastrointestinal bleeding, perforation, obstruction, or penetration to 
liver, pancreas, or colon. We propose a 10-percent evaluation for 
recurring dyspepsia that requires continuous treatment with 
prescription medication for control.
    We also propose to add a note under the general rating formula for 
ulcer disease stating that the diagnosis of ulcer disease or duodenitis 
requires confirmation on at least one occasion by imaging or endoscopy. 
Because the symptoms of ulcer disease are not specific, the note would 
assure that the diagnosis of ulcer disease is not based on symptoms 
alone.

Chronic Gastritis (Diagnostic Code 7307)

    We propose to revise the title of diagnostic code 7307 from the 
current ``gastritis, hypertrophic (identified by gastroscope)'' to 
``chronic gastritis (including but not limited to erosive, 
hypertrophic, hemorrhagic, bile reflux, alcoholic, and drug-induced 
gastritis)'' to indicate that there are several types of gastritis that 
may be evaluated under this code.
    Gastritis is an inflammation of the gastric (stomach) mucosa. 
Common causes include Helicobacter pylori infection, non-steroidal 
anti-inflammatory drugs, alcohol, stress, and autoimmune phenomena 
(atrophic gastritis) (Merck, 117). While chronic gastritis is often 
asymptomatic (symptom-free), it may cause dyspepsia and sometimes 
gastro-intestinal bleeding with resulting anemia. A rare type of 
gastritis results in protein-losing gastropathy (disease of the 
stomach), in which hypoalbuminia (low albumin level in blood), 
diarrhea, weight loss, and edema may occur. Gastritis is currently 
evaluated at 60, 30, or 10 percent, with a 60-percent evaluation 
assigned when the condition is chronic, with severe hemorrhages or 
large ulcerated or eroded areas; a 30-percent evaluation when the 
condition is chronic, ``with multiple small eroded or ulcerated areas, 
and symptoms;'' and a 10-percent evaluation when the condition is 
chronic, ``with small nodular lesions, and symptoms.'' We propose to 
continue these evaluation levels, but to provide different criteria, 
based more on objective clinical findings, which are common indicators 
of disability, than on the pathologic appearance of the gastric mucosa.
    We propose a 60-percent evaluation for any of the following: 
Periodic or continuous dyspepsia with anemia due to gastrointestinal 
bleeding; protein-losing gastropathy with substantial weight loss and 
peripheral edema; or hospitalization two or more times per year for 
gastrointestinal bleeding, intractable vomiting, or other complication 
of chronic gastritis. We propose a 30-percent evaluation for either of 
the following: Protein-losing gastropathy with at least minor weight 
loss, or hospitalization once per year for gastrointestinal bleeding, 
intractable vomiting, or other complication of chronic gastritis. We 
propose a 10-percent evaluation for dyspepsia that requires continuous 
treatment with prescription medication.
    These proposed criteria are similar to those recommended by our 
consultants, but have been modified to remove

[[Page 39165]]

subjective terms, and for the sake of internal consistency. In order to 
document that gastritis, which is often hard to diagnose, is definitely 
present, we also propose to add a note stating that evaluation under 
diagnostic code 7307 requires that the diagnosis of chronic gastritis 
be confirmed on at least one occasion by endoscopy. The condition of 
``gastritis, atrophic'' is listed in the current schedule at the end of 
the criteria for hypertrophic gastritis. It is followed by a statement 
that this is ``a complication of a number of diseases, including 
pernicious anemia,'' and a direction to rate the underlying condition. 
We propose to include this information in a second note under 
diagnostic code 7307, to provide clear guidance to the raters on how to 
evaluate atrophic gastritis.

Postgastrectomy Syndromes (Diagnostic Code 7308)

    Postgastrectomy syndromes (diagnostic code 7308) are currently 
evaluated at levels of 60, 40, or 20 percent, based on frequency of 
episodes of symptoms. A 60-percent evaluation is assigned when the 
condition is severe, meaning that it is associated with nausea, 
sweating, circulatory disturbance after meals, diarrhea, hypoglycemic 
symptoms, and weight loss with malnutrition and anemia; a 40-percent 
evaluation when the condition is moderate, with less frequent episodes 
of epigastric disorders with characteristic mild circulatory symptoms 
after meals but with diarrhea and weight loss; and a 20-percent 
evaluation when the condition is mild, with infrequent episodes of 
epigastric distress with characteristic mild circulatory symptoms or 
continuous mild manifestations.
    We propose to base evaluations of postgastrectomy syndromes on more 
objective criteria, such as the frequency of dumping syndrome (which is 
the common term for the group of symptoms that may occur following 
various types of surgery for ulcer disease), whether there is weight 
loss, malnutrition or anemia, and whether a restricted diet is needed. 
For the sake of simplicity, we propose to list the possible signs and 
symptoms of postgastrectomy syndromes in a note rather than listing all 
possible manifestations at every evaluation level.
    Several types of problems may occur after gastrectomy, with the 
onset, frequency, and types of symptoms varying with the particular 
type of surgery performed (Merck, 123). One problem is the dumping 
syndrome. There are two types of dumping syndrome, an early type that 
occurs within 30 minutes of eating, and a late type that occurs 90 
minutes to 3 hours after eating (``Harrison's Principles of Internal 
Medicine'' 1240 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)). 
Although early and late types have different causes, their symptoms 
overlap. Rather than experiencing a dumping syndrome, some individuals 
experience only severe diarrhea as a major postgastrectomy problem. 
Others experience abdominal pain, bilious vomiting (vomiting of bile), 
anemia, and weight loss due to a condition called alkaline reflux 
gastritis (also called biliary gastritis or bile reflux gastritis); and 
some individuals have malabsorption and poor absorption of vitamins and 
minerals resulting in malnutrition and anemia as their most significant 
problems (Yamada, 1394).
    Since the signs and symptoms of these postgastrectomy syndromes 
overlap, and ``dumping syndrome'' is the commonly used designation for 
postgastrectomy signs and symptoms, we propose to lump the various 
postgastrectomy syndromes together as ``dumping syndrome'' and to add a 
note under diagnostic code 7308 stating that for purposes of evaluation 
under diagnostic code 7308, the term ``dumping syndrome'' includes 
symptoms that are associated with any of the following postgastrectomy 
syndromes: Early and late types of dumping syndrome, postgastrectomy 
diarrhea, and alkaline reflux gastritis. These symptoms include any 
combination of weakness, dizziness, lightheadedness, diaphoresis 
(sweating), palpitations, tachycardia, postural hypotension, confusion, 
syncope (fainting), nausea, vomiting (often with bile), diarrhea, 
steatorrhea (fatty stools), borborygmi (audible rumbling bowel sounds), 
abdominal pain, anorexia (lack or loss of appetite), abdominal 
bloating, and belching. In order to include both types of 
postgastrectomy dumping syndromes, we also propose to state, in the 
same note, that symptoms may occur immediately after eating or up to 
three hours later.
    We propose to provide evaluation levels of 100, 60, 30, and 10 
percent, instead of the current 60, 40, and 20 percent. Our consultants 
suggested that we add a 100-percent evaluation level, since 
postgastrectomy syndromes may be severely disabling, and we propose to 
do so. As with gastritis, to promote consistent evaluations, we propose 
to substitute a 30-percent evaluation level for the 20- and 40-percent 
levels to provide a clearer distinction between adjacent levels. We 
also propose to add a 10-percent evaluation level for milder cases of 
dumping syndrome. We propose a 100-percent evaluation for dumping 
syndrome that occurs after most meals, with substantial weight loss, 
malnutrition, and anemia. We propose a 60-percent evaluation for 
dumping syndrome that occurs after most meals, with substantial weight 
loss and anemia. We propose a 30-percent evaluation for dumping 
syndrome that occurs daily or nearly so, despite treatment, with at 
least minor weight loss. We propose a 10-percent evaluation for 
intermittent dumping syndrome (occurring at least three times a week) 
requiring dietary restrictions.
    Our consultants suggested criteria that retain the same subjective 
terms of ``infrequent,'' ``mild,'' and ``less frequent,'' as the 
current schedule. For example, our consultants recommended that a 20-
percent evaluation be assigned for post-gastrectomy syndrome that is 
``mild'' with ``infrequent'' episodes of epigastric distress with 
``characteristic mild'' circulatory symptoms or continuous ``mild'' 
manifestations. We propose to use more specific terms such as ``after 
most meals'' and ``daily or nearly so,'' since making the criteria less 
ambiguous is one of the goals of the revision of the rating schedule. 
In order to make the criteria clear to everyone who uses the rating 
schedule, we propose to list the actual symptoms (many of which 
overlap) of hypoglycemia and circulatory disturbance in the note 
defining dumping syndrome, rather than use less clear terms such as 
``hypoglycemic symptoms'' or ``circulatory symptoms,'' as the 
consultants suggested. We also propose a second note to direct raters 
to separately evaluate complications, such as osteomalacia, under an 
appropriate diagnostic code.

Gastric Emptying Disorders (Diagnostic Code 7309)

    Diagnostic code 7309 is currently titled ``stomach, stenosis of'' 
and includes an instruction to ``[r]ate as for gastric ulcer'' 
(diagnostic code 7304), which in turn is usually rated as duodenal 
ulcer (diagnostic code 7305). We propose to make diagnostic code 7309 
more inclusive by changing the title to ``gastric emptying disorders 
(including gastroparesis (delayed gastric emptying), and pyloric, 
gastric, and other motility disturbances)'' because all of these 
conditions, which are not uncommon and are not currently listed in the 
current rating schedule, may produce similar signs and symptoms.
    We propose to provide evaluation levels of 100, 60, 30, and 10 
percent for diagnostic code 7309. As our consultants pointed out, these 
conditions can be very debilitating. We

[[Page 39166]]

propose to base the evaluation on criteria specific to gastric emptying 
disorders--epigastric pain or fullness, anorexia (lack or loss of 
appetite), nausea, vomiting, gastroesophageal reflux, early satiety 
(feeling that hunger and thirst are satisfied), and abdominal bloating 
(Yamada, 1264). We propose to add a note listing the signs and symptoms 
of gastric emptying disorders, for purposes of evaluation under 
diagnostic code 7309.
    We propose a 100-percent evaluation for daily or near-daily signs 
and symptoms with substantial weight loss and malnutrition. We propose 
a 60-percent evaluation for periodic or daily or near-daily signs and 
symptoms with substantial weight loss. We propose a 30-percent 
evaluation for periodic signs and symptoms with minor weight loss. We 
propose a 10-percent evaluation for periodic signs and symptoms without 
weight loss, but requiring continuous treatment with prescription 
medication. These criteria are specific to the disability and are 
clearer and more objective than those proposed by our consultants. 
While the consultants used similar symptoms, they also included 
modifiers like ``pronounced,'' ``severe,'' and ``moderate,'' which are 
subjective terms that we are trying to exclude from the rating schedule 
when possible, for the sake of consistent evaluations.

Injury of the Stomach (Diagnostic Code 7310)

    Injury of the stomach, diagnostic code 7310, is currently evaluated 
under the criteria for peritoneal adhesions (diagnostic code 7301). We 
propose to retain that direction and to add an alternative direction, 
as recommended by our consultants, to evaluate as postgastrectomy 
syndromes (diagnostic code 7308) if the injury required a gastric 
resection.

Liver Disease

    In a separate rulemaking, we previously revised the portion of 
Sec.  4.114 that addresses liver disease, including injury of the liver 
(diagnostic code 7311), cirrhosis of the liver (diagnostic code 7312), 
deletion of residuals of abscess of liver (diagnostic code 7313), 
infectious hepatitis (diagnostic code 7345), benign new growths of the 
digestive system (7344), and malignant new growths of the digestive 
system, exclusive of skin growths (diagnostic code 7343). Following 
notice and comment, this rulemaking was published as a final rule on 
May 31, 2001 (66 FR 29486). We do not propose any further changes to 
those diagnostic codes.

Biliary Tract Disease or Injury (Diagnostic Code 7314)

    Diagnostic code 7314 is currently titled ``cholecystitis, chronic'' 
and has evaluation levels of 30, 10, and zero percent. A 30-percent 
evaluation is assigned if the condition is severe, with frequent 
attacks of gall bladder colic; a 10-percent evaluation if the condition 
is moderate, with gall bladder dyspepsia, confirmed by X-ray technique, 
and with infrequent attacks (not over two or three a year) of gall 
bladder colic, with or without jaundice; and a zero-percent evaluation 
if the condition is mild.
    Chronic cholelithiasis (diagnostic code 7315) and chronic 
cholangitis (diagnostic code 7316) are evaluated under the same 
criteria as chronic cholecystitis. All of these conditions are closely 
related and may co-exist, and can readily be evaluated under a single 
diagnostic code and set of evaluation criteria. In addition, diagnostic 
code 7318, ``Gall bladder, removal of,'' can result in signs and 
symptoms similar to those of the above three conditions. It is 
currently evaluated at 30, 10, or zero percent, under subjectively-
defined criteria. A 30-percent evaluation is assigned if there are 
``severe symptoms,'' a 10-percent evaluation if there are ``mild 
symptoms,'' and a zero-percent evaluation if the condition is 
nonsymptomatic. ``Gall bladder, injury of'' (diagnostic code 7317) is 
currently rated as peritoneal adhesions.
    We, therefore, propose to revise the title of diagnostic code 7314 
to the more inclusive ``Biliary tract disease or injury (chronic 
cholecystitis, cholelithiasis, choledocholithiasis, chronic 
cholangitis, status post-cholecystectomy, gall bladder or bile duct 
injury, biliary dyskinesia, cholesterolosis, polyps of gall bladder, 
sclerosing cholangitis, stricture or infection of the bile ducts, 
choledochal cyst)'' because all of these conditions are related and may 
produce similar effects. It is therefore appropriate to evaluate them 
under the same criteria. It is not uncommon for more than one of these 
conditions to be present at the same time, and using a single set of 
criteria would better allow an appropriate overall evaluation in those 
cases, since the signs and symptoms overlap and may be identical. Our 
consultants did not suggest combining these conditions under a single 
diagnostic code, as we are proposing, but did suggest evaluating them 
under the same criteria. The evaluation criteria we are proposing are 
similar to those they suggested, but would eliminate the subjective 
terms ``severe,'' ``moderate'' and ``mild''.
    Although the current evaluation levels for these conditions are 
limited to 30, 10, and zero percent, we propose to provide evaluation 
levels of 100, 60, 30, and 10 percent for biliary tract disease or 
injury, to accommodate more severe cases, including those that are 
totally disabling. We propose to base evaluations on the frequency of 
acute attacks of signs and symptoms of biliary tract disease or injury 
per year; the frequency of hospitalizations for biliary tract disease 
or injury per year; the response to medical or surgical treatment; and 
whether liver failure is present. We propose to describe the usual 
signs and symptoms of biliary tract disease and injury in a note, as 
discussed below.
    We propose a 100-percent evaluation for any of the following: Near-
constant debilitating attacks of biliary tract disease or injury that 
are refractory to medical or surgical treatment; liver failure; or 
hospitalization three or more times per year for biliary tract disease 
or injury. We propose a 60-percent evaluation for either of the 
following: Six or more attacks of biliary tract disease or injury per 
year, partially responsive to treatment; or hospitalization two times 
per year for biliary tract disease or injury. We propose a 30-percent 
evaluation for either of the following: Three to five attacks of 
biliary tract disease or injury per year, or hospitalization once per 
year for biliary tract disease or injury. We propose a 10-percent 
evaluation for either of the following: One or two attacks of biliary 
tract disease or injury per year; or biliary tract pain occurring at 
least monthly, despite medical treatment. We propose to remove the 
zero-percent level as unnecessary (see Sec.  4.31).
    The proposed criteria would provide more objective criteria for 
evaluating these conditions and also provide a wider range of 
percentage evaluations, consistent with the potential disabling effects 
of these conditions.
    We propose to add four notes under diagnostic code 7314, with the 
first stating that for purposes of evaluation under diagnostic code 
7314, attacks of biliary tract disease or injury include any 
combination of such signs and symptoms as abdominal pain (including 
biliary colic), dyspepsia, jaundice, anorexia (lack or loss of 
appetite), nausea, vomiting, chills, and fever (Merck, 242-245). So 
that the presence of biliary tract disease is substantiated, and not 
based on symptoms alone, the second proposed note would state that 
evaluation under diagnostic code 7314 requires that the diagnosis of 
any of these conditions be confirmed by X-ray

[[Page 39167]]

or other imaging procedure, laboratory findings, or other objective 
evidence. The third proposed note would direct raters to separately 
evaluate peritoneal adhesions (diagnostic code 7301) if applicable, and 
combine (under the provisions of Sec.  4.25) with an evaluation under 
diagnostic code 7314, as long as the same findings are not used to 
support more than one evaluation. This would assure that traumatic or 
postoperative manifestations due to adhesions would be properly 
evaluated. The fourth proposed note would direct raters to evaluate the 
cirrhotic phase of sclerosing cholangitis under diagnostic code 7312 
(cirrhosis of liver), a more appropriate diagnostic code for evaluating 
that condition than 7314.
    Since chronic cholelithiasis (current diagnostic code 7315), 
chronic cholangitis (current diagnostic code 7316), injury of gall 
bladder (current diagnostic code 7317), and removal of gall bladder 
(current diagnostic code 7318) would all be included in diagnostic code 
7314, for reasons discussed above, we propose to delete the separate 
diagnostic codes for those conditions.

Disease or Injury of the Spleen

    There is currently a reference to disease or injury of the spleen 
under diagnostic code 7318, directing raters to the hemic and lymphatic 
systems. We propose to remove that reference as unnecessary, since the 
spleen, although in the abdominal cavity, is part of the lymphatic, not 
the digestive system. Evaluation criteria for splenectomy (diagnostic 
code 7706) and healed injury of the spleen (diagnostic code 7707) are 
included in the hemic and lymphatic portion of the rating schedule (38 
CFR 4.117), and both conditions are listed in the index to the rating 
schedule as part of the hemic and lymphatic systems.

Irritable Bowel Syndrome (Diagnostic Code 7319)

    Diagnostic code 7319 is currently titled ``Irritable colon syndrome 
(spastic colitis, mucous colitis, etc.).'' We propose to retitle it 
``Irritable bowel syndrome (irritable colon, spastic colitis, mucous 
colitis),'' since this is current terminology for the condition. The 
current evaluation levels are 30, 10, and zero percent. A 30-percent 
evaluation is assigned if the condition is severe, with diarrhea or 
alternating diarrhea and constipation, with more or less constant 
abdominal distress. A 10-percent evaluation is assigned if the 
condition is moderate, with frequent episodes of bowel disturbance with 
abdominal distress. A zero-percent evaluation is assigned if the 
condition is mild, with ``disturbances of bowel function with 
occasional episodes of abdominal distress.'' Our consultants suggested 
evaluation levels of 30 and 10 percent, with essentially the same 
criteria as the current ones, except for adding ``refractory to medical 
treatment'' to the criteria for 30 percent, and ``partially responsive 
to treatment'' to the criteria for 10 percent. We are proposing to 
remove the subjective terms ``severe,'' ``frequent,'' ``occasional,'' 
etc., from the criteria and to base evaluation on more objective 
criteria, in order to decrease the reliance on ambiguous descriptive 
terms. We propose a 30-percent evaluation for daily or near-daily 
disturbances of bowel function (diarrhea, or alternating diarrhea and 
constipation), bloating, and abdominal cramping or pain, refractory to 
medical treatment, and a 10-percent evaluation for disturbances of 
bowel function (diarrhea, or alternating diarrhea and constipation), 
bloating, and abdominal cramping or pain that occur three or more times 
a month and that respond partially to medical treatment. We propose to 
remove the zero-percent level as unnecessary (see Sec.  4.31). These 
proposed criteria would ensure consistency of evaluations and still be 
in keeping with our consultants' recommendations.

Amebiasis and Bacillary Dysentery

    In the current rating schedule, diagnostic code 7321 is amebiasis, 
and diagnostic code 7322 is bacillary dysentery. Both conditions are 
uncommon today except as acute short-term illnesses. They ordinarily 
resolve without residuals because they are highly responsive to modern 
drug treatment. In accordance with our consultants' suggestion, we 
therefore propose to delete diagnostic code 7321 and diagnostic code 
7322 as unnecessary.

Ulcerative Colitis (Diagnostic Code 7323)

    Ulcerative colitis (diagnostic code 7323) is currently evaluated at 
100, 60 30, or 10 percent. A 100-percent evaluation is assigned if the 
condition is pronounced, resulting in marked malnutrition, anemia, and 
general debility, or if there are serious complications, such as liver 
abscess. A 60-percent evaluation is assigned if the condition is 
severe, with numerous attacks a year and malnutrition, with the health 
only fair during remissions. A 30-percent evaluation is assigned if the 
condition is moderately severe, with frequent exacerbations; and a 10-
percent evaluation is assigned if the condition is moderate, with 
infrequent exacerbations.
    The most common symptoms of ulcerative colitis are abdominal pain 
and bloody diarrhea, but there may also be rectal pain, fever, 
tachycardia, anorexia, malaise, weakness, and other symptoms. In severe 
cases, there may be weight loss, malnutrition, anemia, and 
hypoalbuminemia. Common complications include perforation, stricture, 
hemorrhage, dehydration, fulminant (sudden and intense) colitis, and 
toxic megacolon (a severe distention of the colon that can be life 
threatening). Among other possible complications are liver disease, 
skin nodules, eye problems, colon cancer, and arthritis (Merck, 155-156 
and http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm#symptoms, National Digestive Diseases Information 
Clearinghouse, February 2006).
    Our consultants suggested we continue evaluations based on 
frequency of episodes, attacks, and exacerbations, and they provided 
some timeframes for their frequency and duration. We propose to use 
their suggestions, in a modified form, removing the subjective language 
such as ``severe'' and ``marked'' that they included. We also further 
propose to specify the usual symptoms of ulcerative colitis in the 
criteria, with bloody diarrhea being the major symptom, and to include 
criteria based on the need for hospitalization for complications or 
continuous treatment with prescription medication. We propose a 100-
percent evaluation for either of the following: malnutrition, 
substantial weight loss, anemia, and general debility with multiple 
attacks of colitis per year, with bloody diarrhea, abdominal or rectal 
pain, fever, and malaise; or hospitalization three or more times per 
year for complications such as hemorrhage, dehydration, obstruction, 
fulminant (sudden and intense) colitis, toxic megacolon, or 
perforation.
    We propose a 60-percent evaluation for either of the following: 
substantial weight loss and anemia, with multiple attacks of colitis 
per year, with bloody diarrhea, abdominal or rectal pain, fever, and 
malaise; or hospitalization two times per year for complications such 
as hemorrhage, dehydration, obstruction, fulminant colitis, toxic 
megacolon, or perforation. We propose a 30-percent evaluation for 
either of the following: three or more attacks of colitis (each lasting 
5 or more days) per year, with diarrhea with blood, pus, or mucous, and 
abdominal or rectal pain; or hospitalization one time per year for

[[Page 39168]]

complications such as hemorrhage, dehydration, obstruction, fulminant 
colitis, toxic megacolon, or perforation. We propose a 10-percent 
evaluation for either of the following: One or two attacks of colitis 
(each lasting 5 or more days) per year with diarrhea with blood, pus, 
or mucous, and abdominal or rectal pain; or continuous treatment with 
prescription medication either to control symptoms or to maintain 
remission.
    We also propose to add a note directing raters to evaluate other 
complications, such as uveitis, ankylosing spondylitis, sclerosing 
cholangitis, etc., separately under an appropriate diagnostic code. We 
propose to add a second note directing raters, if there has been a 
colon resection, to evaluate under diagnostic codes 7350 (colostomy or 
ileostomy) and 7329 (resection of large intestine), as applicable, and 
to combine the evaluations under the provisions of Sec.  4.25, as long 
as the same findings are not used to support more than one evaluation.

Intestinal Parasitic Infections (Diagnostic Code 7324)

    We propose to change the title of diagnostic code 7324 from 
``distomiasis, intestinal or hepatic'' to ``parasitic infections of the 
intestinal tract'' because our consultants advised us that distomiasis 
(formerly used to refer to trematodes or flukes) is a term that is no 
longer used. The generic term ``parasitic infections'' includes all 
types of parasitic infections, not just trematodes or flukes. Parasitic 
infections that do not primarily affect the digestive tract are 
evaluated in the portion of the rating schedule that addresses 
Infectious Diseases, Immune Disorders and Nutritional Deficiencies. The 
current evaluation criteria, with levels of 30, 10, and zero percent, 
are based on whether there are ``severe,'' ``moderate,'' or ``mild'' 
symptoms, with no specific guidance as to the type of symptoms.
    Our consultants suggested criteria of ``severe symptoms including 
diarrhea, abdominal distress, and weight loss, refractory to medical 
treatment'' for a 30-percent evaluation and ``moderate symptoms'' for a 
10-percent evaluation. While more specific than the current criteria, 
they retain subjective language. We propose to remove the subjective 
terms and base evaluation on the presence of diarrhea (which commonly 
means more than three loose watery stools in one day (http://digestive.niddk.nih.gov/ddiseases/pubs/diarrhea/, National Digestive 
Diseases Information Clearinghouse, October 2003)), abdominal pain, and 
weight loss, and on whether continuous treatment with prescription 
medication is required. We propose to delete the zero-percent level, 
since a parasitic infection that does not meet the criteria for a ten-
percent evaluation would be assigned a non-compensable evaluation, and 
this is sufficiently clear without the need for a zero-percent 
evaluation level (see Sec.  4.31).
    We propose to evaluate parasitic infections of the intestinal tract 
at 30 percent if there is daily diarrhea (occurring more than three 
times per day) and abdominal pain, with at least minor weight loss. We 
propose to evaluate them at 10 percent if diarrhea and abdominal pain 
occur, and they require continuous treatment with prescription 
medication for control. In addition, since parasitic infection of the 
gastrointestinal tract may result in a malabsorption syndrome, we 
propose to add a note directing raters to evaluate under proposed 
diagnostic code 7353 (malabsorption syndrome), if malabsorption is 
present, and doing so would result in a higher evaluation.

Chronic Diarrhea of Unknown Etiology (Diagnostic Code 7325)

    Diagnostic code 7325 is currently titled ``Enteritis, chronic'' and 
directs that the condition be rated as irritable colon syndrome 
(diagnostic code 7319). At the suggestion of our consultants, we 
propose to revise the title to ``chronic diarrhea of unknown etiology'' 
because chronic enteritis is no longer considered a specific diagnostic 
entity. We also propose to provide evaluation criteria specific to this 
condition, in accordance with the recommendation of our consultants, 
since those for evaluating irritable colon syndrome (which include 
``alternating constipation and diarrhea'') are not appropriate for 
evaluating chronic diarrhea.
    We propose to provide evaluation levels of 60, 30, and 10 percent 
(our consultants recommended levels of 60 and 30 percent) based on the 
frequency of watery bowel movements, their requirement for and response 
to medical treatment, and on the number of episodes per year of fluid 
and electrolyte imbalance requiring parenteral (intravenous or 
intramuscular) hydration. We propose a 60-percent evaluation if there 
are five or more watery bowel movements daily, refractory to medical 
treatment, and three or more episodes per year of fluid and electrolyte 
imbalance requiring parenteral (intravenous or intramuscular) 
hydration. We propose a 30-percent evaluation if there are five or more 
watery bowel movements daily, partially responsive to medical 
treatment, and one or two episodes per year of fluid and electrolyte 
imbalance requiring parenteral (intravenous or intramuscular) 
hydration. We propose a 10-percent evaluation if the condition requires 
continuous treatment with prescription medication for control.
    These criteria for evaluating chronic diarrhea of unknown etiology 
are both objective and specific to the disability, and are in general 
agreement with the suggestions of our consultants, although they 
recommended that we require at least six watery bowel movements per 
day, instead of five or more, as we are proposing. In our judgment, 
five or more watery bowel movements a day constitute a sufficient 
indication of severity of the major disabling symptom of this 
condition. The consultants also recommended a 60-percent evaluation for 
one episode of biochemical alteration, but it is our opinion that one 
episode would not be sufficiently disabling to warrant a 60-percent 
evaluation, in comparison to other disabilities evaluated at a 60-
percent level. We propose instead that there be three or more episodes 
of fluid and electrolyte imbalance to warrant a 60-percent evaluation, 
and one or two episodes to warrant a 30-percent evaluation.

Crohn's Disease (Diagnostic Code 7326)

    Diagnostic code 7326 is currently titled ``Enterocolitis, chronic'' 
and directs that the condition be rated as irritable colon syndrome 
(diagnostic code 7319), with evaluation levels of 30, 10, and zero-
percent, but as suggested by our consultants, we propose to change the 
title to ``Crohn's disease,'' the current medical term for this 
condition, and to provide criteria more specific to the disabling 
effects of this disease. Our consultants pointed out that Crohn's 
disease can be very disabling, and we therefore propose to provide a 
broader range of evaluation levels--100, 60, 30, and 10 percent--in 
order to encompass the whole range of disabling effects that may result 
from this condition. The most common signs and symptoms of Crohn's 
disease, which is often episodic, include diarrhea, abdominal pain and 
tenderness, fever, anorexia, and weight loss; also there may be pallor, 
weakness, malnutrition, abscesses, fistula, bowel obstruction, and 
other complications, as pointed out by our consultants, and as found in 
standard medical books (Merck, 153; Yamada, 1599).
    We propose a 100-percent evaluation for either of the following: 
multiple attacks or flareups of Crohn's disease per year with abdominal 
pain or tenderness, diarrhea, fever, anorexia

[[Page 39169]]

(lack or loss of appetite), and fatigue plus malnutrition, substantial 
weight loss, hypoalbuminemia, and anemia; or hospitalization three or 
more times per year for complications such as abscess, stricture, 
obstruction, or fistula.
    We propose a 60-percent evaluation for any of the following: 
multiple attacks or flareups of Crohn's disease per year with abdominal 
pain or tenderness, diarrhea, fever, anorexia (lack or loss of 
appetite), and fatigue plus substantial weight loss and anemia; 
hospitalization two times per year for recurrent complications such as 
abscess, stricture, obstruction, or fistula; or constant or near-
constant treatment with high dose systemic (oral or parenteral 
[intravenous or intramuscular]) corticosteroids.
    We propose a 30-percent evaluation for any of the following: three 
or more attacks or flareups of Crohn's disease per year with abdominal 
pain or tenderness, diarrhea, fever, anorexia (lack or loss of 
appetite), and fatigue, plus at least minor weight loss; 
hospitalization one time per year for complications such as abscess, 
stricture, obstruction, or fistula; or three or more (but not constant) 
courses of treatment per year with high dose systemic (oral or 
parenteral [intravenous or intramuscular]) corticosteroids.
    We propose a 10-percent evaluation for any of the following: One or 
two attacks or flareups of Crohn's disease per year with abdominal pain 
or tenderness, diarrhea, and fever; one or two courses of treatment per 
year with high dose systemic (oral or parenteral [intravenous or 
intramuscular]) corticosteroids; or continuous treatment with 
prescription medication other than high dose systemic (oral or 
parenteral [intravenous or intramuscular]) corticosteroids.
    These criteria are more specific to Crohn's disease than those in 
the current rating schedule, and represent modifications of the 
criteria suggested by our consultants (for example, to remove 
subjective language). They would provide a clear and objective basis 
for evaluation, as well as a suitable range of evaluation levels.
    We also propose to add a note directing raters to evaluate 
complications, such as external gastrointestinal fistula, arthritis, 
episcleritis (inflammation of the outer layers of the sclera of the 
eye), etc., separately under an appropriate diagnostic code as long as 
the same findings are not used to support more than one evaluation (see 
Sec.  4.14). We propose to add a second note, because bowel surgery is 
often needed, directing raters to evaluate under diagnostic code 7350 
(colostomy or ileostomy) if an ostomy is present, and under diagnostic 
code 7328 (resection of the small intestine) or 7329 (resection of 
large intestine), if applicable, as long as the same findings are not 
used to support more than one evaluation.

Diverticulitis (Diagnostic Code 7327)

    The current rating schedule does not provide specific criteria for 
diverticulitis, diagnostic code 7327, but directs that it be evaluated 
as either irritable colon syndrome (diagnostic code 7319), peritoneal 
adhesions (diagnostic code 7301), or ulcerative colitis (diagnostic 
code 7323), depending on the predominant disability picture. We propose 
to provide evaluation criteria specific to this condition, with 
evaluation levels of 100, 60, 30, and 10 percent, to reflect its range 
of severity. The most common signs and symptoms of diverticulitis are 
abdominal pain and tenderness, fever, and an elevated white blood count 
(Merck, 160; Yamada, 1737). There may also be peritoneal irritation, 
with or without bleeding; irregular defecation; and such complications 
as fistula formation, intestinal obstruction, abscess formation, or 
perforation. Milder attacks can be treated with antibiotics, bed rest, 
and a liquid diet as an outpatient, but more serious attacks may 
require hospitalization for intravenous antibiotics and other measures, 
and, sometimes, surgery.
    We therefore propose a 100-percent evaluation for either of the 
following: near-constant signs and symptoms of diverticulitis, with 
abdominal pain and tenderness, fever, and irregular defecation 
(constipation, diarrhea, or alternating constipation and diarrhea); or 
hospitalization at least three times per year for complications such as 
abscess, perforation, obstruction, or fistula.
    We propose a 60-percent evaluation for any of the following: six or 
more attacks of diverticulitis per year with abdominal pain and 
tenderness, fever, and irregular defecation (constipation, diarrhea, or 
alternating constipation and diarrhea), requiring outpatient treatment 
with a course of antibiotics, bed rest, and a liquid diet; 
hospitalization two times per year for complications such as abscess, 
perforation, obstruction, or fistula; or hospitalization three or more 
times per year for acute diverticulitis requiring intravenous 
antibiotics.
    We propose a 30-percent evaluation for any of the following: three 
to five attacks of diverticulitis per year with abdominal pain and 
tenderness, fever, and irregular defecation (constipation, diarrhea, or 
alternating constipation and diarrhea), requiring outpatient treatment 
with a course of antibiotics, bed rest, and a liquid diet; 
hospitalization one time per year for complications such as abscess, 
perforation, obstruction, or fistula; or hospitalization once or twice 
per year for acute diverticulitis requiring intravenous antibiotics.
    We propose a 10-percent evaluation for the following: One or two 
attacks of diverticulitis per year with abdominal pain and tenderness, 
fever, and irregular defecation (constipation, diarrhea, or alternating 
constipation and diarrhea), requiring a course of antibiotics.
    We also propose to add a note to address evaluation after surgery, 
which is often needed to treat diverticulitis. The note would direct 
raters to evaluate under diagnostic code 7350 (colostomy or ileostomy) 
if an ostomy is present, and under diagnostic code 7329 (resection of 
large intestine), if applicable, as long as the same findings are not 
used to support more than one evaluation (see Sec.  4.14).
    These criteria are similar to those suggested by our consultants, 
but modified, to remove indefinite terms such as ``severe,'' 
``moderate,'' and ``frequent,'' and to substitute criteria that are 
both more specific and more objective, in order to promote consistent 
evaluations.

Resection of Small Intestine (Diagnostic Code 7328)

    Resection of the small intestine, diagnostic code 7328, currently 
has evaluation levels of 60, 40 and 20 percent, with criteria for the 
various levels based on the extent of interference with absorption and 
nutrition, the degree of impairment of health with either weight loss 
or inability to gain weight, and whether there are symptoms. A 60-
percent evaluation is assigned if the condition shows marked 
interference with absorption and nutrition, manifested by severe 
impairment of health objectively supported by examination findings 
including material weight loss; a 40-percent evaluation if the 
condition produces definite interference with absorption and nutrition, 
manifested by impairment of health objectively supported by examination 
findings, including definite weight loss; and a 20-percent evaluation 
if the condition is symptomatic, with diarrhea, anemia, and inability 
to gain weight. These criteria contain indefinite criteria, such as 
``material'' or ``definite'' weight loss and ``marked'' or ``definite'' 
interference with absorption. In addition, our consultants advised us 
that the current criteria, based partly on weight loss or inability to 
gain weight, are no longer

[[Page 39170]]

appropriate because the parenteral (intravenous or intramuscular) and 
supplemental nutrition now available will ordinarily allow body weight 
to be maintained. They pointed out that the type and frequency of 
nutritional support needed is related to the severity of the condition.
    We therefore propose to provide evaluation criteria that are both 
more objective and more characteristic of the disabling effects of 
resection of the small intestine than the current criteria, in light of 
modern medicine. We propose that the condition be evaluated based on 
the need for oral or parenteral (intravenous or intramuscular) 
nutritional support and on the presence of diarrhea and other symptoms. 
Our consultants said that the need for total parenteral (intravenous or 
intramuscular) nutrition indicates a debilitating condition that would 
be totally disabling. We therefore propose a 100-percent evaluation if 
total parenteral (intravenous or intramuscular) nutrition is required. 
We propose a 60-percent evaluation for diarrhea, weakness, fatigue, 
abdominal cramps, and bloating, with anemia, requiring daily (oral) 
nutritional supplementation, plus parenteral (intravenous or 
intramuscular) nutrition for a total of at least 28 days per year; a 
30-percent evaluation for diarrhea, weakness, fatigue, abdominal 
cramps, and bloating requiring daily (oral) nutritional supplementation 
plus parenteral (intravenous or intramuscular) nutrition for a total of 
at least 14 days, but less than 28 days per year; and a 10-percent 
evaluation for diarrhea, weakness, fatigue, abdominal cramps, and 
bloating requiring daily (oral) nutritional supplementation.
    We propose to modify the current note under diagnostic code 7328. 
It now directs that the condition be rated under diagnostic code 7301, 
where residual adhesions constitute the predominant disability. We 
propose that the note instruct raters to separately evaluate peritoneal 
adhesions, diagnostic code 7301, if applicable, as long as the same 
findings are not used to support an evaluation both under diagnostic 
code 7301 and under diagnostic code 7328.

Resection of Large Intestine (Diagnostic Code 7329)

    Resection of the large intestine, diagnostic code 7329, currently 
has evaluation levels of 40, 20, and 10 percent, based on the 
indefinite criteria of whether symptoms are ``severe'' and 
``objectively supported by examination findings'' (for 40 percent), 
``moderate'' (for 20 percent), or ``slight'' (for 10 percent). We 
propose to remove these subjective terms and provide more objective 
criteria based on the primary symptoms of diarrhea and abdominal pain 
and the number of complications, as recommended by our consultants. We 
propose that there be a broader range of evaluation levels, 100, 60, 
30, and 10 percent, consistent with the range of severity of the 
condition.
    We propose a 100-percent evaluation for multiple daily episodes of 
diarrhea and abdominal pain that are refractory to treatment, plus at 
least two hospitalizations per year for complications such as 
obstruction, fistula, or abscess; a 60-percent evaluation for multiple 
attacks of diarrhea and abdominal pain per year requiring medical 
treatment plus at least one hospitalization per year for complications 
such as obstruction, fistula, or abscess; a 30-percent evaluation for 
four or more attacks of diarrhea and abdominal pain per year requiring 
medical treatment; and a 10-percent evaluation for two or three attacks 
per year of diarrhea and abdominal pain requiring medical treatment. 
These criteria are more objective and would therefore promote more 
consistent evaluations, and they are consistent with the disabling 
effects that sometimes occur after large bowel resection. They are 
similar to the suggestions of our consultants, but with less subjective 
language and with modifications of the criteria at various levels, for 
the sake of internal consistency.
    Although the current note following diagnostic code 7329 instructs 
raters to evaluate the condition as peritoneal adhesions, diagnostic 
code 7301, if adhesions are the predominant disability, we propose to 
direct raters to separately evaluate peritoneal adhesions (diagnostic 
code 7301), if applicable, and combine (under the provisions of Sec.  
4.25) with an evaluation under diagnostic code 7329, as long as the 
same findings are not used to support more than one evaluation. This is 
clearer and more appropriate, since evaluation under both cited 
diagnostic codes is feasible under certain circumstances (see Sec.  
4.14, Avoidance of pyramiding). We also propose to add a second note 
directing raters to evaluate under diagnostic code 7350 (colostomy or 
ileostomy), if applicable, and combine (under the provisions of Sec.  
4.25) with an evaluation under diagnostic code 7329, as long as the 
same findings are not used to support more than one evaluation.

External Gastrointestinal Fistula (Diagnostic Code 7330)

    Diagnostic code 7330 is currently titled ``Intestine, fistula of, 
persistent, or after attempt at operative closure.'' External 
gastrointestinal fistulas (fistulas that drain from the 
gastrointestinal tract to the surface of the skin) other than fistulas 
from the intestine are not currently included in the rating schedule. 
Our consultants stated that the symptoms and complications of external 
gastrointestinal fistula include fluid discharge, skin problems, fluid 
and electrolyte imbalance, recurrent sepsis, and malnutrition. We 
propose to base the evaluation on such manifestations, regardless of 
the type of discharge, rather than solely on the presence and amount of 
the discharge. Only fecal discharge is currently evaluated under this 
diagnostic code, and the criteria do not take into account the type of 
treatment or the potential specific effects that might result from 
fecal or other types of discharges. As recommended by our consultants, 
we propose to expand the category of fistula of the intestine and 
change the title to ``external gastrointestinal fistula (including 
biliary, pancreatic, esophageal, gastric, and intestinal fistulas)'' in 
order to include all external fistulas of gastrointestinal origin. The 
current criteria are ``copious and frequent, fecal discharge'' for a 
100-percent evaluation; ``constant or frequent, fecal discharge'' for a 
60-percent evaluation; and ``slight infrequent, fecal discharge'' for a 
30-percent evaluation. The current provision also directs that if 
healed, fistulas are to be rated as peritoneal adhesions. We propose to 
delete the ambiguous and subjective terms ``slight,'' ``frequent,'' and 
``infrequent,'' and replace them with more objective and specific 
criteria, in order to assure more consistent evaluations. We also 
propose to delete the reference to fecal discharge because we are 
proposing that this diagnostic code include fistulas where the 
discharge may be bile, gastric fluid, etc., instead of fecal material. 
We also propose to delete the direction to rate healed fistulas as 
peritoneal adhesions, since our consultants said that adhesions are not 
a usual complication of fistulas.
    Our consultants stated that the symptoms and complications of 
external gastrointestinal fistula include fluid discharge, skin 
problems, fluid and electrolyte imbalance, recurrent sepsis, and 
malnutrition. We propose to base the evaluation on such manifestations,

[[Page 39171]]

rather than simply on the extent and frequency of fecal discharge.
    We propose a 100-percent evaluation for external gastrointestinal 
fistula if there is constant or near-constant copious discharge that 
cannot be contained, and any of the following is present: A need for 
total parenteral (intravenous or intramuscular) nutritional support, 
malnutrition, seven or more episodes per year of fluid and electrolyte 
imbalance requiring parenteral (intravenous or intramuscular) 
hydration, or two or more episodes per year of sepsis (a serious and 
sometimes life-threatening infection with a widespread inflammatory 
response). We propose a 60-percent evaluation for constant or near-
constant copious discharge that cannot be contained, and with any of 
the following: Persistent skin breakdown, despite treatment, five or 
six episodes per year of fluid and electrolyte imbalance requiring 
parenteral (intravenous or intramuscular) hydration, or one episode of 
sepsis per year. We propose a 30-percent evaluation for constant or 
intermittent discharge with either of the following: Six or more 
episodes per year of skin breakdown requiring treatment, or two to four 
episodes per year of fluid and electrolyte imbalance requiring 
parenteral (intravenous or intramuscular) hydration. We propose a 10-
percent evaluation for constant or intermittent discharge with either 
of the following: At least two, but less than six, episodes per year of 
skin breakdown requiring treatment, or one episode per year of fluid 
and electrolyte imbalance requiring parenteral (intravenous or 
intramuscular) hydration.
    The proposed criteria are more precise and better take into account 
the actual disabling effects of a fistula. These changes would provide 
raters with clearly delineated objective criteria for evaluation and 
are in general agreement with revisions suggested by our consultants. 
Our consultants recommended that we direct raters to evaluate internal 
gastrointestinal fistulas (fistulas that drain from one area of the 
gastrointestinal tract to another) under the criteria for malabsorption 
(diagnostic code 7353) or other appropriate condition, depending on the 
particular findings, since malabsorption is a common effect of internal 
fistulas. We propose to add this direction in a note under diagnostic 
code 7330.

Tuberculous Peritonitis (Diagnostic Code 7331)

    Diagnostic code 7331, ``peritonitis, tuberculous, active or 
inactive,'' currently directs that inactive tuberculous peritonitis be 
evaluated under Sec. Sec.  4.88b or 4.89 (of this part). We propose to 
correct this reference because Sec.  4.88b was redesignated Sec.  4.88c 
in a separate rulemaking (59 FR 60902), which was published in the 
Federal Register on November 29, 1994. The correct section references 
should be 4.88c and 4.89. Otherwise, we propose no change to the rating 
criteria, but we do propose to simplify the title of this diagnostic 
code to ``Tuberculous peritonitis.''

Impaired Control of the Anal Sphincter (Diagnostic Code 7332)

    Diagnostic code 7332 is currently titled ``Rectum and anus, 
impairment of sphincter control.'' We propose to change the title to 
``Impaired control of the anal sphincter (anal incontinence)'' for more 
accuracy, because our consultants stated that inclusion of the rectum 
in this category is not appropriate, since the sphincter is actually an 
anal, rather than a rectal, structure. There are currently evaluation 
levels of 100, 60, 30, 10 and zero percent. A 100-percent evaluation is 
assigned if there is complete loss of sphincter control; a 60-percent 
evaluation if there is extensive leakage and fairly frequent 
involuntary bowel movements; a 30-percent evaluation if there are 
occasional involuntary bowel movements necessitating wearing of pad; a 
10-percent evaluation if there is constant slight, or occasional 
moderate leakage; and a zero-percent evaluation if the condition is 
healed or slight, without leakage. These criteria contain numerous 
indefinite terms, such as ``extensive,'' ``frequent,'' ``occasional,'' 
and ``slight,'' that allow different individuals to make different 
interpretations of the criteria.
    We propose to retain evaluation levels of 100, 60, 30, and 10 
percent, but omit the zero-percent evaluation level as unnecessary (see 
Sec.  4.31). We further propose to make the criteria more objective by 
basing them on the specific frequency of fecal soiling, the extent of 
inability to control solid or liquid feces, and the need for wearing 
absorbent material. We propose a 100-percent evaluation if there is 
complete inability to control solid and liquid feces; a 60-percent 
evaluation if there is daily fecal soiling and complete inability to 
control liquid feces; a 30-percent evaluation if there is fecal soiling 
that, although less than daily, is frequent enough or extensive enough 
to require daily wearing of absorbent material; and a 10-percent 
evaluation if there is fecal soiling that is intermittent, and not 
frequent enough or extensive enough to require daily wearing of 
absorbent material. We propose to remove the zero-percent level as 
unnecessary (see Sec.  4.31). These more objective and condition-
specific criteria would promote consistent evaluations of this 
disability and are in general agreement with, although more detailed 
than, the revisions suggested by our consultants. They also exclude the 
subjective terms such as ``pronounced'' and ``moderate'' that our 
consultants used. We also propose to add a note directing raters to 
evaluate under diagnostic code 7350 (colostomy or ileostomy) if an 
ostomy is present, since fecal incontinence may require a colostomy.

Stricture of the Anus (Diagnostic Code 7333)

    Diagnostic code 7333 is currently titled ``Rectum and anus, 
stricture of.'' Because our consultants suggested that rectal 
strictures would be more appropriately evaluated with bowel strictures 
under diagnostic code 7349, we propose to remove rectal strictures from 
this diagnostic code and change the title to ``Stricture of the anus.'' 
The current evaluation criteria are ``requiring colostomy,'' for a 100-
percent evaluation; ``great reduction of lumen, or extensive leakage,'' 
for a 50-percent evaluation; and ``moderate reduction of lumen, or 
moderate constant leakage,'' for a 30-percent evaluation. We propose to 
remove the indefinite terms, such as ``great,'' ``extensive,'' and 
``moderate,'' and base the evaluation on objective criteria, such as 
the extent of reduction of the lumen, the frequency and extent of fecal 
soiling, and the necessity for daily wearing of absorbent material.
    Because we are proposing a separate diagnostic code for the 
evaluation of colostomy and ileostomy, there is no longer a need to 
include colostomy in these criteria. We propose to change the current 
evaluation levels of 100, 50, and 30 percent to 100, 60, and 30 
percent, and to add a 10-percent level, for the sake of more internal 
consistency. These are also the levels we propose to provide for 
diagnostic code 7332, and the type and range of disability due to this 
condition are very similar to those of disability due to impaired 
control of the anal sphincter. We propose a 100-percent evaluation if 
there is inability to open or completely close the anus, with complete 
inability to control liquid or solid feces. We propose a 60-percent 
evaluation if there is reduction of the lumen by at least 50 percent, 
with pain and prolonged straining during defecation, and complete 
inability to control liquid feces. We propose a 30-percent evaluation 
if there is reduction of the lumen, but by less than 50 percent, with 
straining during

[[Page 39172]]

defecation, and fecal incontinence that requires daily wearing of 
absorbent material; and a 10-percent evaluation if there is reduction 
of the lumen, with fecal soiling that is not frequent enough or 
extensive enough to require daily wearing of absorbent material.
    Because a colostomy may be required for treatment of this 
condition, we also propose to add a note directing raters to evaluate 
under diagnostic code 7350 (colostomy or ileostomy), if an ostomy is 
present. In addition to proposing more objective criteria in order to 
promote consistency of evaluations, we have proposed criteria that are 
generally in agreement with our consultants' suggestions, excluding the 
subjective modifiers, such as ``moderate'' and ``occasional,'' that 
they used. These criteria are also internally consistent with the 
proposed criteria for evaluating impaired control of the anal 
sphincter.

Prolapse of Rectum (Diagnostic Code 7334)

    Diagnostic code 7334, ``rectum, prolapse of,'' currently has 
evaluation levels of 50, 30, and 10 percent. A 50-percent evaluation is 
assigned if there is ``severe (or complete), persistent'' rectal 
prolapse. A 30-percent evaluation is assigned if there is ``moderate, 
persistent or frequently recurring'' rectal prolapse, and a 10-percent 
evaluation is assigned if there is mild rectal prolapse, ``with 
constant slight or occasional moderate leakage.'' These criteria 
require raters to subjectively determine whether the condition is 
``mild,'' ``moderate,'' or ``severe,'' and what level of frequency the 
term ``frequently recurring'' implies.
    Our consultants noted that incontinence is the major problem 
associated with prolapse of the rectum and that higher evaluation 
levels should be available for this condition. We therefore propose to 
provide levels of 100, 60, 30, and 10 percent, as we are proposing for 
diagnostic codes 7332 and 7333, the codes for other conditions that are 
also characterized primarily by fecal incontinence. We propose to 
remove the subjective language and base evaluation on more objective 
criteria, such as the frequency of prolapse, the presence of 
incontinence, and the extent of fecal soiling.
    We propose a 100-percent evaluation for persistent prolapse with 
complete inability to control liquid or solid feces; a 60-percent 
evaluation for intermittent prolapse (occurring three or more times 
weekly) with complete inability to control liquid or solid feces during 
periods of prolapse; a 30-percent evaluation for intermittent prolapse 
(occurring three or more times weekly) without complete inability to 
control liquid or solid feces during periods of prolapse, but with 
difficulty in bowel evacuation and fecal soiling that is frequent 
enough or extensive enough to require daily wearing of absorbent 
material; and a 10-percent evaluation if there is intermittent prolapse 
with difficulty in bowel evacuation and fecal soiling that is not 
frequent enough or extensive enough to require daily wearing of 
absorbent material.
    These criteria would promote more consistent evaluations, and they 
provide a range of evaluation levels consistent with the range of 
severity of this condition. Our consultants recommended criteria based 
on frequency of prolapse, whether or not there is incontinence, 
difficult evacuation, and soiling. However, they used numerous 
subjective terms, such as ``mild,'' ``moderate,'' ``severe,'' 
``frequently,'' and ``occasional,'' and our proposed criteria represent 
a modification of their recommendations for the sake of objectivity and 
internal consistency with other digestive condition evaluations.
    Our consultants also recommended that solitary rectal ulcer 
syndrome be included in this code. However, in our experience, this 
condition occurs too infrequently to warrant inclusion, and in 
addition, the symptoms of solitary rectal ulcer syndrome--altered bowel 
habits with blood and mucous in the stool, anorectal pain, a feeling of 
incomplete evacuation, and straining at defecation (Yamada, 1824)--are 
not entirely consistent with the condition-specific criteria we are 
proposing for rectal prolapse. If solitary rectal ulcer syndrome 
requires evaluation, it may be rated as an analogous condition under 
the evaluation criteria for prolapse of the rectum or other digestive 
condition in the rating schedule, depending on the particular signs and 
symptoms found.

Fistula in Ano (Diagnostic Code 7335)

    Fistula in ano, diagnostic code 7335, is currently evaluated as 
impairment of sphincter control, diagnostic code 7332. The current 
evaluation criteria for impairment of sphincter control are not ideal 
for evaluating fistula in ano, however, because they do not take into 
account abscesses with pain and drainage, which our consultants pointed 
out are the primary disabling effects of fistulas. We therefore propose 
to provide a specific set of evaluation criteria based on these 
effects, with evaluation levels of 100, 60, 30, and 10 percent, the 
same levels as for other anal disabilities.
    Fistula in ano may also be called anorectal fistula or anorectal 
abscess, and we propose to add those names to the title. We propose a 
100-percent evaluation for fistula in ano with constant or near-
constant abscesses with drainage and pain that are refractory to 
medical and surgical treatment; a 60-percent evaluation for four or 
more abscesses (each lasting a week or more) per year with drainage and 
pain; a 30-percent evaluation for three or more abscesses (each lasting 
less than a week) per year with drainage and pain ; and a 10-percent 
evaluation either for one or two abscesses (each lasting less than a 
week) per year with drainage and pain, or for a fistula with pain and 
discharge but without associated abscesses. We propose to delete the 
zero-percent evaluation as unnecessary for clarity (see Sec.  4.31). 
These evaluation criteria are better suited and more appropriate for 
evaluating this disability because, in addition to being more 
objective, they are based on the usual disabling effects of fistula in 
ano. They represent modifications of the suggestions made by our 
consultants, faithful in substance, but with some changes made partly 
for the sake of internal consistency and partly to remove subjective 
terms.
    Our consultants suggested we add a diagnostic code for the 
evaluation of other defecation disorders, such as Hirschprung's disease 
(congenital megacolon), anismus (paradoxical pelvic muscle 
contraction), levator spasm syndrome, functional constipation, and 
outlet obstruction. We do not propose to do so because these conditions 
are either uncommon in our experience, congenital in origin and likely 
to disqualify for military service, or have no organic basis. Any 
condition that requires evaluation for compensation purposes can be 
evaluated under existing codes as an analogous condition.

Hemorrhoids (Diagnostic Code 7336)

    Hemorrhoids, external or internal, (diagnostic code 7336) are 
currently evaluated at 20, 10, or zero percent. A 20-percent evaluation 
is provided for ``persistent bleeding and with secondary anemia, or for 
fissures;'' a 10-percent evaluation for hemorrhoids that are ``large or 
thrombotic, irreducible, with excessive redundant tissue, evidencing 
frequent recurrences;'' and a zero-percent evaluation if they are 
``mild or moderate.'' According to our consultants, external 
hemorrhoids are seldom chronically disabling, but can cause 
intermittent problems when they undergo thrombosis. Internal 
hemorrhoids may undergo frequent or permanent prolapse, thrombosis, and 
bleeding sufficient to cause anemia. The

[[Page 39173]]

current evaluation criteria under diagnostic code 7336 do not 
differentiate between internal and external hemorrhoids.
    We propose to change the title of diagnostic code 7336 from 
``hemorrhoids, external or internal'' to ``hemorrhoids,'' because the 
single term encompasses all types of hemorrhoids, and to provide 
criteria that apply in part to any type of hemorrhoids and in part only 
to either internal or external hemorrhoids. We propose to retain 
evaluation levels of 20 and 10 percent, but to remove the zero-percent 
evaluation criteria as unnecessary (see Sec.  4.31). We also propose to 
remove subjective terms such as ``mild,'' ``moderate,'' ``excessive,'' 
and ``frequent'' that are in the current criteria and replace them with 
more objective criteria. We propose a 20-percent evaluation for either 
of the following: Persistent bleeding with anemia, or permanently 
prolapsed internal hemorrhoids with three or more episodes per year of 
thrombosis. We propose a 10-percent evaluation for either permanently 
or intermittently prolapsed internal hemorrhoids with one or two 
episodes per year of thrombosis, or for external hemorrhoids with three 
or more episodes per year of thrombosis. These criteria would provide 
raters with a clear, objective way to evaluate any type of hemorrhoids, 
while taking into account the differences in the disabling effects of 
external and internal hemorrhoids.

Hernia, Inguinal or Femoral (Diagnostic Code 7338)

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

[[Page 39174]]

``moderate,'' ``mild,'' and ``small,'' and they retained the references 
to recurrent hernia. We have already explained why we are not basing 
evaluation on whether or not a hernia is recurrent. In addition, they 
suggested using pain as one of the criteria, but, in our judgment, the 
more objective criteria we are proposing would take pain, a subjective 
symptom, into account as part of the effects of a hernia (for example, 
as part of whether or not a hernia is supportable or reducible, and its 
size), and the more objective criteria would promote accurate and more 
consistent evaluations. For these reasons, we do not propose to adopt 
our consultants' suggestions for the evaluation of hernias.

Ventral Hernia, Postoperative (Diagnostic Code 7339)

    Diagnostic code 7339 is currently titled ``Hernia, ventral, 
postoperative.'' We propose to retitle this diagnostic code as 
``Ventral (incisional) hernia, and other abdominal hernias 
postoperative.'' ``Incisional'' is another term for ventral hernia, and 
other incisional hernias that might not be ventral (flank incisions, 
for example), would also be most appropriately evaluated under this 
diagnostic code. Ventral hernia is currently evaluated at levels of 
100, 40, 20, and zero percent. A 100-percent evaluation is assigned if 
a ventral hernia is massive, persistent, and there is severe diastasis 
of recti muscles or extensive diffuse destruction or weakening of 
muscular and fascial support of the abdominal wall so as to be 
inoperable; a 40-percent evaluation if a hernia is large and not well 
supported by a belt under ordinary conditions; a 20-percent evaluation 
if a hernia is small and not well supported by a belt under ordinary 
conditions, or if there is a healed ventral hernia or postoperative 
wounds with weakening of the abdominal wall and there is an indication 
for a supporting belt; and a zero-percent evaluation if there are 
postoperative wounds that are healed, with no disability, and a belt is 
not indicated. These criteria contain the indefinite terms ``massive,'' 
``large,'' and ``small,'' which could be interpreted differently by 
different people.
    According to our consultants, whether or not a ventral hernia is 
supportable is more useful than size, which is currently used to 
distinguish between the 20- and 40-percent levels of disability. 
However, both to distinguish more clearly the levels of evaluation, and 
because, in our judgment, a large hernia that is not supportable is 
likely to interfere with activities more than a small non-supportable 
hernia, we propose to base evaluation in part on size, but also in part 
on whether or not the hernia is externally supportable. The presence of 
pain or incarceration (being irreducible) is also relevant to the 
extent of disability, according to our consultants. However, as 
discussed above under inguinal and femoral hernias, we consider pain to 
be included as part of the effects of other criteria we are proposing 
to use.
    We propose evaluation levels of 100, 60, 30, and 10 percent for 
ventral hernia, instead of the current levels of 100, 40, 20, and zero 
percent. These levels would provide a range of evaluations appropriate 
to ventral hernias, and allow a clear distinction between the levels, 
while eliminating the large gap between 100 and 40 percent. In our 
opinion, some hernias would fall into the area between 100 and 40 
percent levels of severity. The evaluation levels are also comparable 
to the proposed levels for inguinal and femoral hernia under diagnostic 
code 7338.
    We propose to revise the criteria to make them less ambiguous and 
clearer for more ease of use and consistency of evaluations. For 
example, we propose to provide an evaluation of 100 percent for a 
hernia with a diameter of 30 or more centimeters, rather than employing 
the term ``massive''. In our judgment, a ventral hernia with a diameter 
of 30 centimeters (11.81 inches) or greater is a hernia of such size 
that it would be totally disabling if it cannot be repaired because of 
loss of tissue support. We also propose to remove the reference to 
diastasis of recti muscles because our consultants pointed out that 
diastasis recti is a congenital condition of the abdominal wall that is 
not necessarily accompanied by a hernia. We further propose to 
substitute ``refractory to further operative correction due to 
extensive loss of muscular and fascial support'' in lieu of considered 
``inoperable'' to indicate that it must be the status of the hernia 
itself, rather than unrelated medical reasons, that makes the hernia 
unsuitable for surgical correction.
    We therefore propose a 100-percent evaluation for a ventral hernia 
with both of the following: greatest diameter is 30 centimeters (11.81 
inches) or more and is refractory to further operative correction due 
to extensive loss of muscular and fascial support. We propose a 60-
percent evaluation for a ventral hernia with both of the following: 
greatest diameter is 20 centimeters (7.87 inches) or more and requires 
support but is not well supported by external devices or is not easily 
reducible. We propose a 30-percent evaluation for the same criteria as 
for a 60-percent evaluation except that it applies to a ventral hernia 
with greatest diameter less than 20 centimeters (7.87 inches), and a 
10-percent evaluation for a ventral hernia of any size that requires 
support, and is supportable by external devices, and that is easily 
reducible. We also propose to delete the zero-percent level, with 
current criteria of postoperative wounds that are healed, with no 
disability, and a belt not indicated, since those criteria all indicate 
the absence of any disability and are not necessary for evaluation.

Visceroptosis

    Our consultants noted that the term ``visceroptosis,'' the title of 
current diagnostic code 7342, is obsolete. This term was used to 
describe variations in positions of the organs in the body, which 
medical practitioners once considered to be significant. The differing 
positions of the organs are currently viewed as normal anatomical 
variations that are of no pathological significance. We therefore 
propose to delete diagnostic code 7342 from the schedule.

Gastroesophageal Reflux Disease (Diagnostic Code 7346)

    Hiatal hernia is currently evaluated under diagnostic code 7346. 
According to our consultants, the most disabling manifestation of 
hiatal hernia is gastroesophageal reflux. To reflect this fact, we 
propose to change the title of diagnostic code 7346 from ``hernia 
hiatal'' to ``gastroesophageal reflux disease (GERD), hiatal hernia, 
esophagitis, lower esophageal (Schatzki's) ring.'' These conditions are 
closely related, and their symptoms overlap, so evaluating them under 
the same criteria is appropriate and would promote more consistent 
evaluations. The current evaluation levels are 60, 30, and 10 percent. 
We propose to retain these levels, and to add a zero-percent level for 
the sake of clarity. The current criteria under diagnostic code 7346 
call for a 60-percent evaluation if there are ``symptoms of pain, 
vomiting, material weight loss[,] and hematemesis or melena with 
moderate anemia, or other symptom combinations productive of severe 
impairment of health;'' a 30-percent evaluation if there is 
persistently ``recurrent epigastric distress with dysphagia, pyrosis, 
and regurgitation, accompanied by substernal or arm or shoulder pain, 
productive of considerable impairment of health;'' and a 10-percent 
evaluation if there are two or more of the same symptoms as for the 30-
percent evaluation, but of less severity.

[[Page 39175]]

    These criteria rely on subjective interpretations of terms such as 
``severe'' or ``considerable'' impairment of health, symptoms of ``less 
severity,'' and ``persistently recurrent'' symptoms and could lead to 
different interpretations by different individuals. We propose to 
remove the indefinite language and base evaluation on more objective 
criteria that are also more inclusive of the effects of this group of 
conditions than the current evaluation criteria. The proposed criteria 
would be based on such signs and symptoms as the presence of erosive 
reflux esophagitis, anemia, hemorrhage, weight loss, and pulmonary 
aspiration, and of certain symptoms such as pyrosis, retrosternal or 
arm or shoulder pain, dysphagia, and odynophagia.
    We propose a 60-percent evaluation for erosive reflux esophagitis 
(inflammation and ulceration of the esophagus due to reflux of gastric 
contents into the esophagus) confirmed by endoscopy, imaging, or other 
laboratory procedure, with at least one of the following: anemia and 
substantial weight loss, one or more episodes per year of 
gastrointestinal hemorrhage, or two or more episodes per year of 
pulmonary aspiration (with bronchitis, pneumonia, or pulmonary abscess) 
due to regurgitation. We propose a 30-percent evaluation for confirmed 
erosive reflux esophagitis, with symptoms such as pyrosis (heartburn), 
retrosternal or arm or shoulder pain, regurgitation of gastric contents 
into the mouth, dysphagia (difficulty swallowing), and odynophagia 
(pain during swallowing) that are intractable despite treatment, or 
with one episode per year of pulmonary aspiration (with bronchitis, 
pneumonia, or pulmonary abscess) due to regurgitation. We propose a 10-
percent evaluation for the same symptoms as for the 30-percent level, 
but that are largely controlled by continuous treatment with 
prescription medication; and a zero-percent evaluation for the same 
symptoms, but that are intermittent and that respond to dietary 
changes, lifestyle changes, or treatment with antacids or other 
nonprescription medications. In this case, we are proposing a zero-
percent level because the criteria that are provided list items such as 
lifestyle and dietary changes that are not otherwise addressed in the 
criteria but that are used to treat these conditions, and it might be 
unclear to raters whether they warrant a zero- or a 10-percent 
evaluation. These criteria are in general agreement with the 
suggestions of our consultants, but with replacement of subjective 
language such as ``mild,'' ``moderate,'' and ``severe'' with more 
objective criteria.
    We also propose to add a note directing that raters evaluate 
esophageal stricture, which may result from esophagitis, under the 
General Rating Formula for Residuals of mouth injuries (7200), 
Residuals of lip injuries (7201), Residuals of tongue injuries, 
including tongue loss (7202), Esophageal stricture (7203), Achalasia 
(cardiospasm) and other motor disorders of the esophagus (7204), and 
Esophageal diverticula (7205).

Pancreatitis, Total Pancreatectomy, and Partial Pancreatectomy 
(Diagnostic Code 7347)

    Diagnostic code 7347, pancreatitis, is currently evaluated at 
levels of 100, 60, 30, or 10 percent. The criteria call for a 100-
percent evaluation if there are frequently recurrent disabling attacks 
of abdominal pain with few pain free intermissions and with 
steatorrhea, malabsorption, diarrhea and severe malnutrition; a 60-
percent evaluation if there are frequent attacks of abdominal pain, 
loss of normal body weight, and other findings showing continuous 
pancreatic insufficiency between acute attacks; a 30-percent evaluation 
if the condition is moderately severe, with at least 4-7 typical 
attacks of abdominal pain per year with good remission between attacks; 
and a 10-percent evaluation if there is at least one recurring attack 
of typical severe abdominal pain in the past year. We propose to 
evaluate pancreatitis on the basis of similar criteria, but to remove 
the indefinite adjectives ``frequent,'' ``severe,'' and ``moderately 
severe'' in favor of more objective criteria.
    We propose a 100-percent evaluation if all of the following are 
present: daily or near-daily debilitating attacks of pancreatitis (to 
be defined in a note) with few pain-free intermissions; two or more 
signs of pancreatic insufficiency (such as steatorrhea, diabetes, 
malabsorption, diarrhea, and malnutrition); and unresponsive to medical 
treatment. We propose a 60-percent evaluation if the following is 
present: seven or more documented attacks of pancreatitis per year with 
at least one sign of pancreatic insufficiency (such as steatorrhea, 
diabetes, malabsorption, diarrhea, or malnutrition) between acute 
attacks. We propose a 30-percent evaluation if any of the following is 
present: three to six documented attacks of pancreatitis per year with 
at least one sign of pancreatic insufficiency (such as steatorrhea, 
diabetes, malabsorption, diarrhea, or malnutrition) between acute 
attacks; minimum evaluation following partial pancreatectomy, if 
symptomatic and requiring continuous treatment with prescription 
medication; or minimum evaluation following total pancreatectomy. We 
propose a 10-percent evaluation for one or two documented attacks of 
pancreatitis per year, and a zero-percent evaluation for partial 
pancreatectomy, if asymptomatic and not requiring continuous treatment 
with prescription medication. We are proposing to add the zero-percent 
evaluation level for asymptomatic partial pancreatectomy, since it 
might not be clear to raters what the evaluation would be in this case, 
and as recommended by our consultants.
    Total pancreatectomy is disabling in that it requires the 
administration of pancreatic enzymes and insulin (``Textbook of 
Surgery'' 1096 (David C. Sabiston, Jr., M.D., ed., 14th ed. 1991)), 
but, according to our consultants, a partial pancreatectomy without 
residual symptoms and not requiring ongoing medical treatment is not 
disabling. These criteria are generally in accord with the suggestions 
of our consultants and are more objective and measurable than the 
current criteria. They would, therefore, promote consistent 
evaluations.
    Including information about pancreatectomy in the criteria 
themselves makes the current note on that subject (note two under 
current diagnostic code 7347) unnecessary, and we propose to delete it. 
Current note one under diagnostic code 7347 states, ``Abdominal pain in 
this condition must be confirmed as resulting from pancreatitis by 
appropriate laboratory and clinical studies.'' We propose to retain 
that note, but to edit it, and to add a paragraph describing the signs 
and symptoms of an attack of pancreatitis. Note one would say that for 
purposes of evaluation under diagnostic code 7347, an attack of 
pancreatitis means abdominal pain, often very severe, and sometimes 
radiating through to the back, with any combination of nausea, 
vomiting, anorexia (lack or loss of appetite), fever, and abdominal 
tenderness and swelling. (Merck, 1129 and http://digestive.niddk.nih.gov/ddiseases/pubs/pancreatitis/index.htm#acute, 
National Digestive Diseases Information Clearinghouse, February 2004). 
These symptoms must be confirmed as resulting from pancreatitis by 
appropriate laboratory and clinical studies.
    We propose to add a second note directing raters to evaluate 
complications, such as diabetes mellitus, external gastrointestinal 
fistula, and malabsorption, separately under an appropriate diagnostic 
code, as

[[Page 39176]]

long as the same findings are not used to support more than one 
evaluation.

Pyloroplasty With Vagotomy or Gastroenterostomy With Vagotomy 
(Diagnostic Code 7348)

    Vagotomy with pyloroplasty or gastroenterostomy, diagnostic code 
7348, is currently evaluated at 40, 30 or 20 percent. A 40-percent 
evaluation is assigned if there are demonstrably confirmative 
postoperative complications of stricture or continuing gastric 
retention; a 30-percent evaluation if there are symptoms and a 
confirmed diagnosis of alkaline gastritis, or of confirmed persisting 
diarrhea; and a 20-percent evaluation if there is recurrent ulcer with 
incomplete vagotomy. There is also a note directing raters to evaluate 
recurrent ulcer following complete vagotomy under diagnostic code 7305 
(duodenal ulcer), with a minimum evaluation of 20 percent, and to rate 
dumping syndrome under diagnostic code 7308 (postgastrectomy 
syndromes). We propose to direct that this condition be evaluated as 
duodenal ulcer (diagnostic code 7305); gastritis (diagnostic code 
7307); postgastrectomy syndromes (diagnostic code 7308); or gastric 
emptying disorders (diagnostic code 7309), depending upon symptoms and 
findings, in order to provide a wide range of objective evaluation 
criteria appropriate to the numerous signs and symptoms that may result 
from this disability, and to assure more consistent evaluations. This 
is in accord with recommendations by our consultants. With the 
directions for using this broader range of evaluation criteria, the 
note is not necessary, and we propose to remove it. In addition, since 
the major impairments from these conditions are ordinarily due to the 
gastric surgery, or to the combined effects of gastric surgery and 
vagotomy, rather than primarily due to the vagotomy, we propose to 
change the title to ``pyloroplasty with vagotomy or gastroenterostomy 
with vagotomy'' to indicate this.

Consultant-Recommended Conditions To Be Added

    Our consultants suggested adding several conditions to the rating 
schedule--gastrointestinal hemorrhage, non-ulcerative dyspepsia, and 
porto-systemic shunting. Our experience has shown that these conditions 
do not occur commonly enough to warrant inclusion. Furthermore, the 
first two are signs or symptoms rather than diseases or injuries, and 
they may not be appropriate in the schedule for that reason. When 
necessary, digestive conditions not listed in the rating schedule can 
be evaluated under analogous codes.

Proposed Conditions To Be Added

    We do propose to add four commonly occurring digestive conditions 
to the rating schedule: Bowel stricture, as diagnostic code 7349, 
colostomy or ileostomy, as diagnostic code 7350, pancreatic transplant, 
as diagnostic code 7352, and malabsorption syndrome, as diagnostic code 
7353, as described below.

Bowel Stricture (Diagnostic Code 7349)

    Currently, the only evaluation criteria in the rating schedule for 
stricture of the bowel are those provided under diagnostic code 7333, 
stricture of the rectum and anus. We are proposing to delete stricture 
of the rectum from diagnostic code 7333, as recommended by our 
consultants, and instead provide a new diagnostic code, diagnostic code 
7349, ``Bowel stricture,'' for the evaluation of stricture of the bowel 
at any level, including the rectum. This would remove the need to 
evaluate a bowel stricture under an analogous code.
    We propose to establish evaluation levels of 60, 30, and 10 percent 
for bowel strictures. These levels are the same as those we are 
proposing for peritoneal adhesions (Diagnostic Code 7301), and the 
evaluation criteria are also almost identical, because partial bowel 
obstruction due to peritoneal adhesions results in similar signs and 
symptoms as bowel stricture. We propose a 60-percent evaluation for six 
or more episodes per year of partial obstruction of the bowel 
(confirmed by an imaging procedure), with typical signs and symptoms; a 
30-percent evaluation for three to five such episodes; and a 10-percent 
evaluation for one or two such episodes. As with peritoneal adhesions, 
we are proposing to add a note to list the typical signs and symptoms 
of bowel stricture. The note would state that they include colicky 
abdominal pain and at least one of the following other symptoms: 
Abdominal distention, borborygmi (audible rumbling bowel sounds), 
nausea, vomiting, and obstipation (severe constipation). These proposed 
criteria are specific to the condition, are objective, and are similar 
to criteria we are proposing to use to evaluate peritoneal adhesions, 
as recommended by our consultants.

Colostomy or Ileostomy (Diagnostic Code 7350)

    In the current rating schedule, colostomy is mentioned only under 
diagnostic code 7333, stricture of the rectum and anus, where a 100-
percent evaluation is assigned if a colostomy is required for that 
condition. Since a colostomy (an opening on the abdominal wall from the 
colon) may be required for many conditions, however, and is a common 
finding, we propose to establish a separate code, diagnostic code 7350, 
for the evaluation of either colostomy or ileostomy (an opening on the 
abdominal wall from the ileum), a related and also common condition, 
with evaluation criteria specific to these disabilities.
    Individuals vary in the extent of disability they experience 
following ileostomy or colostomy. For example, following ileostomy, 
patients generally return to an active physical life and resume their 
previous work, and restriction of their activities may vary from mild 
to severe (Yamada, 799). Many patients with a colostomy, and some with 
an ileostomy, do not require a bag or appliance (Sabiston, 903; Yamada, 
799). Some individuals, however, have persistent infection or other 
ostomy problems that may be very disabling. We therefore propose to 
base the evaluation on whether or not there is an ostomy complication 
and on whether or not the ostomy is continent.
    We propose to provide evaluation levels of 100, 60, and 30 percent, 
in order to provide a range of appropriate evaluation levels. We 
propose a 100-percent evaluation for at least one ostomy complication 
(such as infection or signs of irritation of the peristomal area, 
prolapse, retraction, or stenosis) that is refractory to treatment; a 
60-percent evaluation for incontinence, requiring the use of an 
external appliance or absorbent material; and a 30-percent evaluation 
if the individual is continent, with no external appliance or absorbent 
material required.

Pancreas Transplant (Diagnostic Code 7352)

    We propose to add pancreatic transplant as diagnostic code 7352, 
because this surgical procedure has been developed since the current 
schedule went into effect and is done frequently enough to warrant 
inclusion. We propose a 100-percent evaluation following transplant 
surgery. We further propose the addition of a note explaining the 
requirement of a VA examination one year following hospital discharge. 
We propose to provide instructions to evaluate thereafter on residuals, 
based on the VA examination, and subject to the provisions of 38 CFR 
3.105(e). Any proposed reduction would be based on the examination, and 
the notification process could begin only

[[Page 39177]]

after the examination had been reviewed. This gives the claimant 
current notice of any proposed action and the opportunity to present 
evidence showing that the proposed action should not be taken. We 
propose a minimum 30-percent evaluation for pancreatic transplant, 
because of the need for long-term immunosuppressive medication and its 
associated problems. The evaluation criteria we are proposing are the 
same as those used for kidney transplant (diagnostic code 7531) in the 
genitourinary section of the rating schedule, because both types of 
transplant require similar periods of convalescence and long-term 
immunosuppressive therapy following convalescence.

Malabsorption Syndrome (Diagnostic Code 7353)

    Malabsorption syndrome (including celiac disease, small bowel 
bacterial overgrowth, Whipple's disease (intestinal lipodystrophy), and 
fistulous disorders) is a common syndrome that can result from a number 
of conditions and result in significant impairment, and we propose to 
add it as diagnostic code 7353, with evaluation levels of 100, 60, 30, 
and 10 percent. We propose a 100-percent evaluation if total parenteral 
(intravenous or intramuscular) nutritional support is required; a 60-
percent evaluation for diarrhea, anemia, weakness, and fatigue 
requiring daily (oral) nutritional supplementation, plus parenteral 
(intravenous or intramuscular) nutrition for a total of at least 28 
days per year; a 30-percent evaluation for diarrhea, weakness, and 
fatigue requiring daily (oral) nutritional supplementation, plus 
parenteral (intravenous or intramuscular) nutrition for a total of at 
least 14 days, but less than 28 days per year; and a 10-percent 
evaluation for diarrhea, weakness, and fatigue requiring daily (oral) 
nutritional supplementation. These are similar to the criteria proposed 
for small bowel resection (diagnostic code 7328) because the effects 
are similar. Our consultants recommended that the diagnosis of 
malabsorption syndrome be confirmed based on a fecal fat loss of 17mEq 
or greater per day. However, this is not the primary diagnostic test 
for every type of malabsorption syndrome, and we do not propose to 
require it.

Paperwork Reduction Act

    This document contains no provisions constituting a collection of 
information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule would not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This proposed rule would not affect any small entities. 
Only VA beneficiaries could be directly affected. Therefore, pursuant 
to 5 U.S.C. 605(b), this proposed rule is exempt from the initial and 
final regulatory flexibility analysis requirements of sections 603 and 
604.

Executive Order 12866

    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, when regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety, 
and other advantages; distributive impacts; and equity). The Executive 
Order classifies a ``significant regulatory action,'' requiring review 
by the Office of Management and Budget (OMB), unless OMB waives such 
review, as any regulatory action that is likely to result in a rule 
that may: (1) Have an annual effect on the economy of $100 million or 
more or adversely affect in a material way the economy, a sector of the 
economy, productivity, competition, jobs, the environment, public 
health or safety, or State, local, or tribal governments or 
communities; (2) create a serious inconsistency or otherwise interfere 
with an action taken or planned by another agency; (3) materially alter 
the budgetary impact of entitlements, grants, user fees, or loan 
programs or the rights and obligations of recipients thereof; or (4) 
raise novel legal or policy issues arising out of legal mandates, the 
President's priorities, or the principles set forth in the Executive 
Order.
    The economic, interagency, budgetary, legal, and policy 
implications of this proposed rule has been examined and it has been 
determined to be a significant regulatory action under Executive Order 
12866 because it is likely to result in a rule that may raise novel 
legal or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in the Executive Order.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in an expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any given year. This proposed rule would have no such 
effect on State, local, and tribal governments, or on the private 
sector.

Catalog of Federal Domestic Assistance Numbers and Titles

    The Catalog of Federal Domestic Assistance program numbers and 
titles for this proposal are 64.104, Pension for Non-Service-Connected 
Disability for Veterans, and 64.109, Veterans Compensation for Service-
Connected Disability.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. John R. 
Gingrich, Chief of Staff, Department of Veterans Affairs, approved this 
document on March 31, 2011, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Dated: June 20, 2011.
William F. Russo,
Deputy Director, Office of Regulation Policy & Management, Department 
of Veterans Affairs.

    For the reasons set forth in the preamble, VA proposes to amend 38 
CFR part 4, subpart B, as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

    1. The authority citation for part 4 continues to read as follows:

    Authority:  38 U.S.C. 1155, unless otherwise noted.

    2. Revise Sec.  4.110 to read as follows:


Sec.  4.110  Dyspepsia.

    For purposes of evaluating conditions in Sec.  4.114, ``dyspepsia'' 
means any combination of the following symptoms: Gnawing or burning 
epigastric or substernal pain that may be relieved by food (especially 
milk) or antacids, nausea, vomiting, anorexia (lack or loss of 
appetite), abdominal bloating, and belching. When there is obstruction 
of the outlet of the stomach (gastric outlet obstruction), dyspepsia 
may also include symptoms of gastroesophageal reflux (flow of stomach 
contents back into the esophagus), borborygmi (audible rumbling bowel 
sounds),

[[Page 39178]]

crampy pain, and obstipation (severe constipation).


Sec.  4.110  [Removed and Reserved]

    3. Remove and reserve Sec.  4.111.

    4. In Sec.  4.112, revise the section heading and add two sentences 
at the end of the paragraph to read as follows:


Sec.  4.112  Weight loss and malnutrition.

    * * * ``Malnutrition'' means a deficiency state resulting from 
insufficient intake of one or multiple essential nutrients or the 
inability of the body to absorb, utilize, or retain such nutrients. It 
is characterized by failure of the body to maintain normal organ 
functions and healthy tissues.
    5. Revise Sec.  4.113 to read as follows:


Sec.  4.113  Evaluation of coexisting digestive conditions.

    Separately evaluate two or more conditions in Sec.  4.114 only if 
the signs and symptoms attributed to each are separable. If they are 
not, assign a single evaluation under the diagnostic code that best 
allows evaluation of the overall functional impairment resulting from 
both conditions.

    Authority: (38 U.S.C. 1155)

    6. Amend Sec.  4.114 by:
    a. Removing the introductory text.
    b. Removing diagnostic codes 7315, 7316, 7317, 7318, 7321, 7322, 
7337, 7340, and 7342.
    c. Revising diagnostic codes 7200 through 7310, 7314 through 7339, 
and 7346 through 7348.
    d. Adding diagnostic codes 7207, 7349, 7350, 7352, and 7353.
    The revisions and additions read as follows:


Sec.  4.114  Schedule of ratings--Digestive system.

------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
7200 Residuals of mouth injuries.
7201 Residuals of lip injuries.
7202 Residuals of tongue injuries, including tongue loss.
7203 Esophageal stricture.
7204 Achalasia (cardiospasm) and other motor disorders of the
 esophagus (diffuse esophageal spasm, corkscrew esophagus,
 nutcracker esophagus, etc.).
7205 Esophageal diverticula, including pharyngoesophageal
 (Zenker's), midesophageal, and epiphrenic types.
General Rating Formula for:
    Residuals of mouth injuries (diagnostic code 7200),
    Residuals of lip injuries (diagnostic code 7201),
    Residuals of tongue injuries, including tongue loss
     (diagnostic code 7202),
    Esophageal stricture (diagnostic code 7203),
    Achalasia (cardiospasm) and other motor disorders of the
     esophagus (diagnostic code 7204), and
    Esophageal diverticulum (diagnostic code 7205):
    With any of the following................................        100
    Tube feeding required;
    Diet restricted to liquid foods, with substantial weight
     loss, malnutrition, and anemia;
    Four or more episodes per year of pulmonary aspiration
     (with bronchitis, pneumonia, or pulmonary abscess) due
     to regurgitation or vomiting; or
    Inability to speak clearly enough to be understood.
    With any of the following................................         60
    Diet restricted to liquid and soft solid foods, with
     substantial weight loss or anemia;
    Two to three episodes per year of pulmonary aspiration
     (with bronchitis, pneumonia, or pulmonary abscess) due
     to regurgitation or vomiting; or
    Inability to speak clearly enough to be understood at
     least half of the time but not all of the time.
    With any of the following................................         30
    Diet restricted to liquid and soft solid foods with minor
     weight loss;
    Esophageal dilation carried out five or more times per
     year;
    Daily regurgitation or vomiting;
    One episode per year of pulmonary aspiration (with
     bronchitis, pneumonia, or pulmonary abscess) due to
     regurgitation or vomiting; or
    Inability to speak clearly enough to be understood at
     times, but less than half of the time;
    With any of the following................................         10
    Diet restricted to liquid and soft solid foods;
    Esophageal dilation carried out one to four times per
     year;
    Heartburn (pyrosis) requiring continuous treatment with
     prescription medication and at least one of the
     following other symptoms: retrosternal chest pain,
     difficulty swallowing (dysphagia), or pain during
     swallowing (odynophagia);
    Partial tongue loss; or
    Impaired articulation for some words, but speech
     understandable.
Note: Separately evaluate mouth and lip injuries under
 diagnostic code 7800 (Burn scar(s) of the head, face, or
 neck; scar(s) of the head, face, or neck due to other
 causes; or other disfigurement of the head, face, or neck),
 if applicable, and combine with an evaluation under this
 general rating formula, under the provisions of Sec.   4.25.
7207 Salivary gland (parotid, submandibular, sublingual)
 disease other than neoplasm:
Xerostomia (dry mouth) with altered sensation of taste and            20
 difficulty with lubrication and mastication of food,
 resulting in either weight loss or increase in dental caries
    With any of the following................................         10
    Xerostomia (dry mouth) with altered sensation of taste
     and difficulty with lubrication and mastication of food,
     but without weight loss or increase in dental caries;
    Chronic inflammation of salivary gland with pain and
     swelling on eating;
    One or more salivary calculi; or
    Salivary gland stricture.
    With either of the following.............................          0
    Xerostomia (dry mouth) without difficulty in mastication
     of food; or
    Painless swelling of salivary gland.

[[Page 39179]]

 
Note (1): Evaluate facial nerve (cranial nerve VII)
 impairment under diagnostic code 8207 (Paralysis of seventh
 (facial) cranial nerve), and any disfigurement due to facial
 swelling under diagnostic code 7800 (Burn scar(s) of the
 head, face, or neck; scar(s) of the head, face, or neck due
 to other causes; or other disfigurement of the head, face,
 or neck)....................................................
Note (2): Xerostomia (dry mouth) is a common symptom of
 Sjogren's syndrome, an autoimmune disorder that also causes
 keratoconjunctivitis sicca (dry eyes), and may affect other
 parts of the body. Evaluate xerostomia due to Sjogren's
 syndrome under diagnostic code 7207, keratoconjunctivitis
 sicca under the portion of the rating schedule that
 addresses Organs of Special Sense, and the effects of the
 syndrome, if any, on other body parts under appropriate
 diagnostic codes............................................
7301 Peritoneal adhesions.
    Six or more episodes per year of partial obstruction of           60
     the bowel (confirmed by X-ray), with typical signs and
     symptoms................................................
    Three to five episodes per year of partial obstruction of         30
     the bowel (confirmed by X-ray), with typical signs and
     symptoms................................................
    One or two episodes per year of partial obstruction of            10
     the bowel (confirmed by X-ray), with typical signs and
     symptoms, or in the absence of such episodes, pulling
     pain on body movement, if not attributable to another
     condition...............................................
Note (1): Evaluation under diagnostic code 7301 requires a
 history of abdominal or pelvic surgery, infection,
 irradiation, trauma, or other known etiology for peritoneal
 adhesions...................................................
Note (2): For purposes of evaluation under diagnostic code
 7301 typical signs and symptoms of partial obstruction of
 the bowel include colicky abdominal pain, and at least one
 of the following other symptoms: abdominal distention,
 borborygmi (audible rumbling bowel sounds), nausea,
 vomiting, and diarrhea......................................
7304 Gastric ulcer.
7305 Duodenal ulcer or duodenitis.
7306 Marginal (gastrojejunal) ulcer.
General Rating Formula for:
    Ulcer Disease (diagnostic code 7304, diagnostic code
     7305, and diagnostic code 7306):
    With either of the following.............................        100
    Substantial weight loss, malnutrition, and anemia due to
     gastrointestinal bleeding; or
    Requiring hospitalization three or more times per year
     for vomiting, refractory pain, gastrointestinal
     bleeding, perforation, obstruction, or penetration to
     liver, pancreas, or colon.
    With either of the following.............................         60
    Periodic or constant dyspepsia with substantial weight
     loss and anemia due to gastrointestinal bleeding; or
    Hospitalization twice per year for vomiting, refractory
     pain, gastrointestinal bleeding, perforation,
     obstruction, or penetration to liver, pancreas, or
     colon.
    With either of the following.............................         30
    Periodic or constant dyspepsia with at least minor weight
     loss; or
    Hospitalization once per year for vomiting, refractory
     pain, gastrointestinal bleeding, perforation,
     obstruction, or penetration to liver, pancreas, or
     colon.
    Recurring dyspepsia that requires continuous treatment            10
     with prescription medication for control................
Note: Evaluation under diagnostic codes 7304, 7305, or 7306
 requires that the diagnosis of ulcer disease or duodenitis
 be confirmed on at least one occasion by imaging or
 endoscopy...................................................
7307 Chronic gastritis (including but not limited to erosive,
 hypertrophic, hemorrhagic, bile reflux, alcoholic, and drug-
 induced gastritis):
    With any of the following................................         60
    Periodic or continuous dyspepsia with anemia due to
     gastrointestinal bleeding;
    Protein-losing gastropathy with substantial weight loss
     and peripheral edema; or
    Hospitalization two or more times per year for
     gastrointestinal bleeding, intractable vomiting, or
     other complication of chronic gastritis.
    With either of the following.............................         30
    Protein-losing gastropathy with at least minor weight
     loss; or
    Hospitalization once per year for gastrointestinal
     bleeding, intractable vomiting, or other complication of
     chronic gastritis.
    Dyspepsia that requires continuous treatment with                 10
     prescription medication.................................
Note (1): Evaluation under diagnostic code 7307 requires that
 the diagnosis of chronic gastritis be confirmed on at least
 one occasion by endoscopy...................................
Note (2): Evaluate atrophic gastritis, which is a
 complication of a number of diseases, including pernicious
 anemia, as part of the underlying condition.................
7308 Postgastrectomy syndromes:
    Dumping syndrome that occurs after most meals, with              100
     substantial weight loss, malnutrition, and anemia.......
    Dumping syndrome that occurs after most meals, with               60
     substantial weight loss and anemia......................
    Dumping syndrome occurring daily or nearly so, despite            30
     treatment, with at least minor weight loss..............
    Intermittent dumping syndrome (occurring at least three           10
     times a week) requiring dietary restrictions............
Note (1): For purposes of evaluation under diagnostic code
 7308, the term ``dumping syndrome'' includes symptoms that
 are associated with any of the following postgastrectomy
 syndromes: early and late types of dumping syndrome,
 postgastrectomy diarrhea, and alkaline reflux gastritis.
 These symptoms include any combination of weakness,
 dizziness, lightheadedness, diaphoresis (sweating),
 palpitations, tachycardia, postural hypotension, confusion,
 syncope (fainting), nausea, vomiting (often with bile),
 diarrhea, steatorrhea (fatty stools), borborygmi (audible
 rumbling bowel sounds), abdominal pain, anorexia (lack or
 loss of appetite), abdominal bloating, and belching.
 Symptoms may occur immediately after eating or up to three
 hours later.................................................
Note (2): Separately evaluate complications, such as
 osteomalacia, under an appropriate diagnostic code..........
7309 Gastric emptying disorders (including gastroparesis
 (delayed gastric emptying), and pyloric, gastric, and other
 motility disturbances):
    Daily or near-daily signs and symptoms with substantial          100
     weight loss and malnutrition............................
    Periodic or daily or near-daily signs and symptoms with           60
     substantial weight loss.................................
    Periodic signs and symptoms with minor weight loss.......         30
    Periodic signs and symptoms, without weight loss, but             10
     requiring continuous treatment with prescription
     medication..............................................
Note: For purposes of evaluation under diagnostic code 7309,
 the signs and symptoms of gastric emptying disorders include
 epigastric pain or fullness and at least one of the
 following other symptoms: anorexia (lack or loss of
 appetite), nausea, vomiting, gastroesophageal reflux, early
 satiety (feeling that hunger and thirst are satisfied), and
 abdominal bloating..........................................
7310 Residuals of injury of the stomach:

[[Page 39180]]

 
    Evaluate as peritoneal adhesions (diagnostic code 7301),
     or, if the injury required a gastric resection, as
     postgastrectomy syndromes (diagnostic code 7308).
 
                              * * * * * * *
7314 Biliary tract disease or injury (chronic cholecystitis,
 cholelithiasis, choledocholithiasis, chronic cholangitis,
 status post-cholecystectomy, gall bladder or bile duct
 injury, biliary dyskinesia, cholesterolosis, polyps of gall
 bladder, sclerosing cholangitis, stricture or infection of
 the bile ducts, choledochal cyst):
    With any of the following................................        100
    Near-constant debilitating attacks of biliary tract
     disease or injury that are refractory to medical or
     surgical treatment;
    Liver failure; or
    Hospitalization three or more times per year for biliary
     tract disease or injury.
    With either of the following.............................         60
    Six or more attacks of biliary tract disease or injury
     per year, partially responsive to treatment; or
    Hospitalization two times per year for biliary tract
     disease or injury.
    With either of the following.............................         30
    Three to five attacks of biliary tract disease or injury
     per year; or
    Hospitalization once per year for biliary tract disease
     or injury.
    With either of the following.............................         10
    One or two attacks of biliary tract disease or injury per
     year; or
    Intermittent biliary tract pain occurring at least
     monthly, despite medical treatment.
Note (1): For purposes of evaluation under diagnostic code
 7314, attacks of biliary tract disease or injury include any
 combination of such signs and symptoms as abdominal pain
 (including biliary colic), dyspepsia, jaundice, anorexia
 (lack or loss of appetite), nausea, vomiting, chills, and
 fever.......................................................
Note (2): Evaluation under diagnostic code 7314 requires that
 the diagnosis of any of these conditions be confirmed by X-
 ray or other imaging procedure, laboratory findings, or
 other objective evidence....................................
Note (3): Separately evaluate peritoneal adhesions
 (diagnostic code 7301), if applicable, and combine (under
 the provisions of Sec.   4.25) with an evaluation under
 diagnostic code 7314, as long as the same findings are not
 used to support more than one evaluation (see Sec.   4.14)..
Note (4): Evaluate the cirrhotic phase of sclerosing
 cholangitis under diagnostic code 7312 (cirrhosis of the
 liver)......................................................
7319 Irritable bowel syndrome (irritable colon, spastic
 colitis, mucous colitis):
    Daily or near-daily disturbances of bowel function                30
     (diarrhea, or alternating diarrhea and constipation),
     bloating, and abdominal cramping or pain, refractory to
     medical treatment.......................................
    Disturbances of bowel function (diarrhea, or alternating          10
     diarrhea and constipation), bloating, and abdominal
     cramping or pain that occur three or more times a month
     and that respond partially to medical treatment.........
7323 Ulcerative colitis:
    With either of the following.............................        100
    Malnutrition, substantial weight loss, anemia, and
     general debility with multiple attacks of colitis per
     year, with bloody diarrhea, abdominal or rectal pain,
     fever, and malaise.
    Hospitalization three or more times per year for
     complications such as hemorrhage, dehydration,
     obstruction, fulminant (sudden and intense) colitis,
     toxic megacolon (a severe distention of the colon that
     can be life threatening), or perforation.
    With either of the following.............................         60
    Substantial weight loss and anemia, with multiple attacks
     of colitis per year, with bloody diarrhea, abdominal or
     rectal pain, fever, and malaise; or
    Hospitalization two times per year for complications such
     as hemorrhage, dehydration, obstruction, fulminant
     (sudden and intense) colitis, toxic megacolon (a severe
     distention of the colon that can be life threatening),
     or perforation.
    With either of the following.............................         30
    Three or more attacks of colitis (each lasting 5 or more
     days) per year, with diarrhea with blood, pus, or mucus,
     and abdominal or rectal pain; or
    Hospitalization one time per year for complications such
     as hemorrhage, dehydration, obstruction, fulminant
     (sudden and intense) colitis, toxic megacolon (a severe
     distention of the colon that can be life threatening),
     or perforation.
    With either of the following.............................         10
    One or two attacks of colitis (each lasting 5 or more
     days) per year with diarrhea with blood, pus, or mucus,
     and abdominal or rectal pain; or
    Continuous treatment with prescription medication either
     to control symptoms or to maintain remission.
Note (1): Separately evaluate other complications, such as
 uveitis, ankylosing spondylitis, and sclerosing cholangitis,
 under an appropriate diagnostic code........................
Note (2): If there has been a colon resection, evaluate under
 diagnostic codes 7350 (colostomy or ileostomy) and 7329
 (resection of large intestine), as applicable, and combine
 the evaluations under the provisions of Sec.   4.25, as long
 as the same findings are not used to support more than one
 evaluation (see Sec.   4.14)................................
7324 Parasitic infections of the intestinal tract:
    Daily diarrhea (occurring more than three times per day)          30
     and abdominal pain, with at least minor weight loss.....
    Diarrhea and abdominal pain requiring continuous                  10
     treatment with prescription medication for control......
Note: If malabsorption is present, evaluate instead under
 diagnostic code 7353 (malabsorption syndrome), if doing so
 would result in a higher evaluation.........................
7325 Chronic diarrhea of unknown etiology:
    Five or more watery bowel movements occurring daily,              60
     refractory to medical treatment, and with three or more
     episodes per year of fluid and electrolyte imbalance
     requiring parenteral (intravenous or intramuscular)
     hydration...............................................
    Five or more watery bowel movements occurring daily,              30
     partially responsive to medical treatment, and with one
     or two episodes per year of fluid and electrolyte
     imbalance requiring parenteral (intravenous or
     intramuscular) hydration................................
    Requiring continuous treatment with prescription                  10
     medication for control..................................
7326 Crohn's disease:
    With either of the following.............................        100
    Multiple attacks or flareups of Crohn's disease per year
     with abdominal pain or tenderness, diarrhea, fever,
     anorexia (lack or loss of appetite), and fatigue plus
     malnutrition, substantial weight loss, hypoalbuminemia,
     and anemia; or

[[Page 39181]]

 
    Hospitalization three or more times per year for
     complications such as abscess, stricture, obstruction,
     or fistula.
    With any of the following................................         60
    Multiple attacks or flareups of Crohn's disease per year
     with abdominal pain or tenderness, diarrhea, fever,
     anorexia (lack or loss of appetite), and fatigue plus
     substantial weight loss and anemia;
    Hospitalization two times per year for recurrent
     complications such as abscess, stricture, obstruction,
     or fistula; or
    Constant or near-constant treatment with high dose
     systemic (oral or parenteral [intravenous or
     intramuscular]) corticosteroids.
    With any of the following................................         30
    Three or more attacks or flareups of Crohn's disease per
     year with abdominal pain or tenderness, diarrhea, fever,
     anorexia (lack or loss of appetite), and fatigue, plus
     at least minor weight loss;
    Hospitalization one time per year for complications such
     as abscess, stricture, obstruction, or fistula; or
    Three or more (but not constant) courses of treatment per
     year with high dose systemic (oral or parenteral
     [intravenous or intramuscular]) corticosteroids.
    With any of the following................................         10
    One or two attacks or flareups of Crohn's disease per
     year with abdominal pain or tenderness, diarrhea, and
     fever;
    One or two courses of treatment per year with high dose
     systemic (oral or parenteral [intravenous or
     intramuscular]) corticosteroids;
    Continuous treatment with prescription medication other
     than high dose systemic (oral or parenteral [intravenous
     or intramuscular]) corticosteroids.
Note (1): Separately evaluate complications, such as external
 gastrointestinal fistula, arthritis, episcleritis
 (inflammation of the outer layers of the sclera of the eye),
 etc., under an appropriate diagnostic code as long as the
 same findings are not used to support more than one
 evaluation (see Sec.   4.14)................................
Note (2): Evaluate under diagnostic code 7350 (colostomy or
 ileostomy) if an ostomy is present, and under diagnostic
 code 7328 (resection of the small intestine) or 7329
 (resection of large intestine), if applicable, as long as
 the same findings are not used to support more than one
 evaluation (see Sec.   4.14)................................
7327 Diverticulitis:
    With either of the following.............................        100
    Near-constant signs and symptoms of diverticulitis, with
     abdominal pain and tenderness, fever, and irregular
     defecation (constipation, diarrhea, or alternating
     constipation and diarrhea); or
    Hospitalization at least three times per year for
     complications such as abscess, perforation, obstruction,
     or fistula.
    With any of the following................................         60
    Six or more attacks of diverticulitis per year with
     abdominal pain and tenderness, fever, and irregular
     defecation (constipation, diarrhea, or alternating
     constipation and diarrhea), requiring outpatient
     treatment with a course of antibiotics, bed rest, and a
     liquid diet;
    Hospitalization two times per year for complications such
     as abscess, perforation, obstruction, or fistula; or
    Hospitalization three or more times per year for acute
     diverticulitis requiring intravenous antibiotics.
    With any of the following................................         30
    Three to five attacks of diverticulitis per year with
     abdominal pain and tenderness, fever, and irregular
     defecation (constipation, diarrhea, or alternating
     constipation and diarrhea), requiring outpatient
     treatment with a course of antibiotics, bed rest, and a
     liquid diet;
    Hospitalization one time per year for complications such
     as abscess, perforation, obstruction, or fistula; or
    Hospitalization once or twice per year for acute
     diverticulitis requiring intravenous antibiotics.
    With one or two attacks of diverticulitis per year with           10
     abdominal pain and tenderness, fever, and irregular
     defecation (constipation, diarrhea, or alternating
     constipation and diarrhea), requiring a course of
     antibiotics.............................................
Note: Evaluate under diagnostic code 7350 (colostomy or
 ileostomy) if an ostomy is present, and under diagnostic
 code 7329 (resection of large intestine), if applicable, as
 long as the same findings are not used to support more than
 one evaluation (see Sec.   4.14)............................
7328 Resection of small intestine:
    Requiring total parenteral (intravenous or intramuscular)        100
     nutritional support.....................................
    Diarrhea, weakness, fatigue, abdominal cramps, and                60
     bloating, with anemia, requiring daily (oral)
     nutritional supplementation, plus parenteral
     (intravenous or intramuscular) nutrition for a total of
     at least 28 days per year...............................
    Diarrhea, weakness, fatigue, abdominal cramps, and                30
     bloating requiring daily (oral) nutritional
     supplementation, plus parenteral (intravenous or
     intramuscular) nutrition for a total of at least 14
     days, but less than 28 days per year....................
    Diarrhea, weakness, fatigue, abdominal cramps, and                10
     bloating requiring daily (oral) nutritional
     supplementation.........................................
Note: Separately evaluate peritoneal adhesions (diagnostic
 code 7301), if applicable, as long as the same findings are
 not used to support an evaluation both under diagnostic code
 7301 and under diagnostic code 7328 (see Sec.   4.14).......
7329 Resection of large intestine:
    Multiple daily episodes of diarrhea and abdominal pain           100
     that are refractory to treatment, plus at least two
     hospitalizations per year for complications such as
     obstruction, fistula, or abscess........................
    Multiple attacks of diarrhea and abdominal pain per year          60
     requiring medical treatment, plus at least one
     hospitalization per year for complications such as
     obstruction, fistula, or abscess........................
    Four or more attacks of diarrhea and abdominal pain per           30
     year requiring medical treatment........................
    Two or three attacks of diarrhea and abdominal pain per           10
     year requiring medical treatment........................
Note (1): Separately evaluate peritoneal adhesions
 (diagnostic code 7301), if applicable, and combine (under
 the provisions of Sec.   4.25) with an evaluation under
 diagnostic code 7329, as long as the same findings are not
 used to support more than one evaluation (see Sec.   4.14)..
Note (2): Evaluate under diagnostic code 7350 (colostomy or
 ileostomy), if applicable, and combine (under the provisions
 of Sec.   4.25) with an evaluation under diagnostic code
 7329, as long as the same findings are not used to support
 more than one evaluation (see Sec.   4.14)..................
7330 External gastrointestinal fistula (including biliary,
 pancreatic, esophageal, gastric, and intestinal fistulas):
    Constant or near-constant copious discharge that cannot          100
     be contained, and with any of the following.............
    Requiring total parenteral (intravenous or intramuscular)
     nutritional support;
    Malnutrition;
    Seven or more episodes per year of fluid and electrolyte
     imbalance requiring parenteral (intravenous or
     intramuscular) hydration; or

[[Page 39182]]

 
    Two or more episodes per year of sepsis (a serious and
     sometimes life-threatening infection with a widespread
     inflammatory response).
    Constant or near-constant, copious discharge that cannot          60
     be contained, and with any of the following.............
    Persistent skin breakdown, despite treatment;
    Five or six episodes per year of fluid and electrolyte
     imbalance requiring parenteral (intravenous or
     intramuscular) hydration; or
    One episode per year of sepsis (a serious and sometimes
     life-threatening infection with a widespread
     inflammatory response).
    Constant or intermittent discharge with either of the             30
     following...............................................
    Six or more episodes per year of skin breakdown that
     require treatment; or
    Two to four episodes per year of fluid and electrolyte
     imbalance requiring parenteral (intravenous or
     intramuscular) hydration.
    Constant or intermittent discharge with either of the             10
     following...............................................
    At least two, but less than six, episodes per year of
     skin breakdown requiring treatment;
    One episode per year of fluid and electrolyte imbalance
     requiring parenteral (intravenous or intramuscular)
     hydration.
Note: Evaluate internal gastrointestinal fistulas (fistulas
 that drain from one area of the gastrointestinal tract to
 another) under the criteria for malabsorption (diagnostic
 code 7353) or other appropriate condition, depending on the
 particular findings.........................................
7331 Tuberculous peritonitis:
    Active...................................................        100
    Inactive: Evaluate in accordance with Sec.  Sec.   4.88c
     or 4.89, whichever is applicable.
7332 Impaired control of the anal sphincter (anal
 incontinence):
    Complete inability to control solid and liquid feces.....        100
    Daily fecal soiling and complete inability to control             60
     liquid feces............................................
    Fecal soiling that, although less than daily, is frequent         30
     enough or extensive enough to require daily wearing of
     absorbent material......................................
    Fecal soiling that is intermittent, and not frequent              10
     enough or extensive enough to require daily wearing of
     absorbent material......................................
Note: Evaluate under diagnostic code 7350 (colostomy or
 ileostomy), if an ostomy is present.........................
7333 Stricture of the anus:
    Inability to open or completely close the anus, with             100
     complete inability to control liquid or solid feces.....
    Reduction of the lumen by at least 50 percent, with pain          60
     and prolonged straining during defecation, and complete
     inability to control liquid feces.......................
    Reduction of the lumen, but by less than 50 percent, with         30
     straining during defecation, and fecal incontinence that
     requires daily wearing of absorbent material............
    Reduction of the lumen, with fecal soiling that is not            10
     frequent enough or extensive enough to require daily
     wearing of absorbent material...........................
Note: Evaluate under diagnostic code 7350 (colostomy or
 ileostomy), if an ostomy is present.........................
7334 Prolapse of rectum:
    Persistent prolapse with complete inability to control           100
     liquid or solid feces...................................
    Intermittent prolapse (occurring three or more times              60
     weekly): with complete inability to control liquid or
     solid feces during periods of prolapse..................
    Intermittent prolapse (occurring three or more times              30
     weekly): without complete inability to control liquid or
     solid feces during periods of prolapse, but with
     difficulty in bowel evacuation and fecal soiling that is
     frequent enough or extensive enough to require daily
     wearing of absorbent material...........................
    Intermittent prolapse with difficulty in bowel evacuation         10
     and fecal soiling that is not frequent enough or
     extensive enough to require daily wearing of absorbent
     material................................................
7335 Fistula in ano (anorectal fistula, anorectal abscess):
    Constant or near-constant abscesses with drainage and            100
     pain, refractory to medical and surgical treatment......
    Four or more abscesses (each lasting a week or more) per          60
     year with drainage and pain.............................
    Three or more abscesses (each lasting less than a week)           30
     per year with drainage and pain.........................
    One or two abscesses (each lasting less than a week) per          10
     year with drainage and pain, or; fistula with pain and
     discharge but without associated abscesses..............
7336 Hemorrhoids:
    With either of the following.............................         20
    Persistent bleeding with anemia; or
    Permanently prolapsed internal hemorrhoids with three or
     more episodes per year of thrombosis.
    With either of the following.............................         10
    Permanently or intermittently prolapsed internal
     hemorrhoids with one or two episodes per year of
     thrombosis; or
    External hemorrhoids with three or more episodes per year
     of Thrombosis.
7338 Hernia, inguinal or femoral (both post-operative
 recurrent and non-operated):
    Hernia with all of the following.........................         60
    Greatest diameter is 15 centimeters (5.91 inches) or
     more;
    Cannot be corrected by surgery; and
    Requires support but is not well supported by external
     devices or is not easily reducible.
    Hernia with all of the following.........................         30
    Greatest diameter is less than 15 centimeters (5.91
     inches);
    Cannot be corrected by surgery; and
    Requires support but is not well supported by external
     devices or is not easily reducible.
    Hernia with all of the following.........................         10
    Of any size;
    Can be corrected by surgery;
    Requires support and is supportable by external devices;
     and
    Easily reducible.
Note: If there are bilateral hernias, evaluate each hernia
 separately, and combine (under the provisions of Sec.
 4.25).......................................................
7339 Ventral (incisional) hernia, and other abdominal hernias
 postoperative:
    Hernia with both of the following........................        100
    Greatest diameter is 30 centimeters (11.81 inches) or
     more; and
    Refractory to further operative correction due to
     extensive loss of muscular and fascial support.

[[Page 39183]]

 
    Hernia with both of the following........................         60
    Greatest diameter is 20 centimeters (7.87 inches) or
     more; and
    Requires support but is not well supported by external
     devices or not easily reducible.
    Hernia with both of the following........................         30
    Greatest diameter is less than 20 centimeters (7.87
     inches); and
    Requires support but is not well supported by external
     devices or not easily reducible.
    Hernia with all of the following.........................         10
    Of any size;
    Requires support and is supportable by external devices;
     and
    Easily reducible.
 
                              * * * * * * *
7346 Gastroesophageal reflux disease (GERD), hiatal hernia,
 esophagitis, lower esophageal (Schatzki's) ring:
    Erosive reflux esophagitis (inflammation and ulceration           60
     of the esophagus due to reflux of gastric contents into
     the esophagus) confirmed by endoscopy, imaging, or other
     laboratory procedure, with at least one of the following
    Anemia and substantial weight loss;
    One or more episodes per year of gastrointestinal
     hemorrhage; or
    Two or more episodes per year of pulmonary aspiration
     (with bronchitis, pneumonia, or pulmonary abscess) due
     to regurgitation.
    Erosive reflux esophagitis (inflammation and ulceration           30
     of the esophagus due to reflux of gastric contents into
     the esophagus) confirmed by endoscopy, imaging, or other
     laboratory procedure, with either of the following......
    Symptoms such as pyrosis (heartburn), retrosternal or arm
     or shoulder pain, regurgitation of gastric contents into
     the mouth, dysphagia (difficulty swallowing), and
     odynophagia (pain during swallowing) that are
     intractable despite treatment; or
    One episode per year of pulmonary aspiration (with
     bronchitis, pneumonia, or pulmonary abscess) due to
     regurgitation.
    Symptoms such as pyrosis (heartburn), retrosternal or arm         10
     or shoulder pain, regurgitation of gastric contents into
     the mouth, dysphagia (difficulty swallowing), and
     odynophagia (pain during swallowing) that are largely
     controlled by continuous treatment with prescription
     medication..............................................
    Intermittent symptoms such as pyrosis (heartburn),                 0
     retrosternal or arm or shoulder pain, regurgitation of
     gastric contents into the mouth, dysphagia (difficulty
     swallowing), and odynophagia (pain during swallowing)
     that respond to dietary changes, lifestyle changes, or
     treatment with antacids or other nonprescription
     medications.............................................
Note: Evaluate esophageal strictures under the General Rating
 Formula for Residuals of mouth injuries (7200), Residuals of
 lip injuries (7201), Residuals of tongue injuries, including
 tongue loss (7202), Esophageal stricture (7203), Achalasia
 (cardiospasm) and other motor disorders of the esophagus
 (7204), and Esophageal diverticula (7205)...................
7347 Pancreatitis, total pancreatectomy, and partial
 pancreatectomy:
    With all of the following................................        100
    Daily or near-daily debilitating attacks of pancreatitis
     with few pain-free intermissions;
    Two or more signs of pancreatic insufficiency (such as
     steatorrhea, diabetes, malabsorption, diarrhea, and
     malnutrition); and
    Unresponsive to medical treatment.
    With the following.......................................         60
    Seven or more documented attacks of pancreatitis per year
     with at least one sign of pancreatic insufficiency (such
     as steatorrhea, diabetes, malabsorption, diarrhea, or
     malnutrition) between acute attacks.
    With any of the following................................         30
    Three to six documented attacks of pancreatitis per year
     with at least one sign of pancreatic insufficiency (such
     as steatorrhea, diabetes, malabsorption, diarrhea, or
     malnutrition) between acute attacks;
    Minimum evaluation following partial pancreatectomy, if
     symptomatic and requiring continuous treatment with
     prescription medication; or
    Minimum evaluation following total pancreatectomy.
    One or two documented attacks of pancreatitis per year...         10
    Partial pancreatectomy, if asymptomatic and not requiring          0
     continuous treatment with prescription medication.......
Note (1): For purposes of evaluation under diagnostic code
 7347, an attack of pancreatitis means abdominal pain, often
 very severe, and sometimes radiating through to the back,
 with any combination of nausea, vomiting, anorexia (lack or
 loss of appetite), fever, and abdominal tenderness and
 swelling....................................................
    Evaluation under diagnostic code 7347 requires that the
     attacks of abdominal pain and other symptoms be
     confirmed by appropriate laboratory and clinical studies
     as resulting from pancreatitis
Note (2): Separately evaluate complications, such as diabetes
 mellitus, external gastrointestinal fistula, and
 malabsorption, as long as the same findings are not used to
 support more than one evaluation (see Sec.   4.14)..........
7348 Pyloroplasty with vagotomy or gastroenterostomy with
 vagotomy:
    Depending upon symptoms and findings, evaluate as:
     duodenal ulcer (diagnostic code 7305); gastritis
     (diagnostic code 7307); postgastrectomy syndromes
     (diagnostic code 7308); or gastric emptying disorders
     (diagnostic code 7309).
7349 Bowel stricture:
    Six or more episodes per year of partial obstruction of           60
     the bowel (confirmed by an imaging procedure), with
     typical signs and symptoms..............................
    Three to five episodes per year of partial obstruction of         30
     the bowel (confirmed by an imaging procedure), with
     typical signs and symptoms..............................
    One or two episodes per year of partial obstruction of            10
     the bowel (confirmed by an imaging procedure), with
     typical signs and symptoms..............................
Note: For purposes of evaluation under diagnostic code 7349,
 typical signs and symptoms of bowel stricture include
 colicky abdominal pain, and at least one of the following
 other symptoms: abdominal distention, borborygmi (audible
 rumbling bowel sounds), nausea, vomiting, and obstipation
 (severe constipation).......................................
7350 Colostomy or ileostomy:
    With at least one ostomy complication (such as infection         100
     or signs of irritation of the peristomal area, prolapse,
     retraction, or stenosis) that is refractory to treatment
    Incontinent, requiring the use of an external appliance           60
     or absorbent material...................................
    Continent, not requiring external appliance or absorbent          30
     material................................................

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                              * * * * * * *
7352 Pancreas transplant:
    Following transplant surgery.............................        100
    Thereafter, evaluate on residuals. Minimum evaluation 30
     percent.
Note: The 100 percent rating shall be assigned as of the date
 of hospital admission for transplant surgery and shall
 continue with a mandatory VA examination one year following
 hospital discharge. Any change in evaluation shall be
 subject to the provisions of Sec.   3.105(e) of this chapter
7353 Malabsorption syndrome (including celiac disease, small
 bowel bacterial overgrowth, Whipple's disease (intestinal
 lipodystrophy), and fistulous disorders):
    Requiring total parenteral (intravenous or intramuscular)        100
     nutritional support.....................................
    Diarrhea, anemia, weakness, and fatigue requiring daily           60
     (oral) nutritional supplementation, plus parenteral
     (intravenous or intramuscular) nutrition for a total of
     at least 28 days per year...............................
    Diarrhea, weakness, and fatigue requiring daily (oral)            30
     nutritional supplementation plus parenteral (intravenous
     or intramuscular) nutrition for a total of at least 14
     days, but less than 28 days per year....................
    Diarrhea, weakness, and fatigue requiring daily (oral)            10
     nutritional supplementation.............................
 
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[FR Doc. 2011-15698 Filed 7-1-11; 8:45 am]
BILLING CODE 8320-01-P