[Federal Register Volume 82, Number 146 (Tuesday, August 1, 2017)]
[Proposed Rules]
[Pages 35719-35733]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-15766]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AP88
Schedule for Rating Disabilities; Musculoskeletal System and
Muscle Injuries
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) proposes to revise the
regulations that involve the Musculoskeletal System within the VA
Schedule for Rating Disabilities (``VASRD'' or ``Rating Schedule''). VA
proposes to rename certain diagnostic codes, revise rating criteria,
give new rating guidance, add new codes, and remove obsolete codes.
These revisions would incorporate medical terminology more recent than
the last comprehensive review, as well as simplify the rating process.
DATES: Comments must be received by VA on or before October 2, 2017.
ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to Director, Regulations
Management (00REG), Department of Veterans Affairs, 810 Vermont Ave.
NW., Room 1068, Washington, DC 20420; or by fax to (202) 273-9026.
(This is not a toll-free number.) Comments should indicate that they
are submitted in response to ``RIN 2900-AP88--Schedule for Rating
Disabilities; Musculoskeletal System and Muscle Injuries.'' Copies of
comments received will be available for public inspection in the Office
of Regulation Policy and Management, Room 1063B, between the hours of
8:00 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 (FDMS) at
www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Regulations Staff
(211C), Compensation Service, Veterans Benefits Administration,
Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC
20420, (202) 461-9700. (This is not a toll-free number.)
SUPPLEMENTARY INFORMATION: The National Defense Authorization Act of
2004, secs. 1501-07, Public Law 108-136, 117 Stat. 1392, established
the Veterans' Disability Benefits Commission (the ``Commission'').
Section 1502 of Public Law 108-136 mandated the Commission to study
ways to improve the disability compensation system for military
veterans. The Commission consulted with the Institute of Medicine (IOM)
to review the medical aspects of current compensation policies. In
2007, the IOM released its report titled ``A 21st Century System for
Evaluating Veterans for Disability Benefits.'' (Michael McGeary et al.
eds.2007).
The IOM report was notable in several respects. The IOM observed
that, in part, the Rating Schedule was inadequate in areas because it
contained obsolete information and did not
[[Page 35720]]
sufficiently integrate current and accepted diagnostic procedures. In
addition, the IOM observed that the current body system organization of
the Rating Schedule does not reflect current knowledge of the
relationships between conditions and comorbidities.
Following the release of the IOM report, VA created a
musculoskeletal system workgroup. The goals adopted by the workgroup
were to: (1) Improve and update the process that VA uses to assign
levels of disability after it grants service connection; (2) improve
the fairness in adjudicating disability benefits for service-connected
veterans; and (3) invite public participation. The workgroup was co-
chaired by the Veterans Health Administration and Veterans Benefits
Administration. The workgroup was comprised of subject matter experts
from VA, the Department of Defense, and medical academia. The workgroup
held a public forum in Washington, DC, during August 2010, where it
discussed current regulations and possible revisions. The workgroup
held a second public forum in Washington, DC, during June 2012, where
it shared a draft proposal for comment.
The workgroup met periodically during and after the public forums
to continue its revision efforts. The regulation-drafting phase, which
began in April 2012, continues through the publication of this proposed
rule. With this rulemaking, VA proposes to remove obsolete diagnostic
codes, modernize the names of selected diagnostic codes, revise
descriptions and criteria, and add new diagnostic codes.
The Focus of This Revision
Consistent with the IOM's recommendations, the proposed amendments
rename conditions to reflect current medicine, remove obsolete
conditions, clarify ambiguities in existing rating criteria, and add
conditions that previously did not have diagnostic codes. However, VA
experienced greater difficulty revising existing rating criteria in
many areas. After significant time and research, since an earnings loss
study had not been conducted in time to be considered during the
workgroup and rule-drafting phases, VA concluded there was only a
narrow set of circumstances where the medical literature clearly
supported the proposed changes in the absence of earnings loss
information.
As such, VA modified the approach recommended by the IOM for this
body system. Only peer-reviewed articles where at least one measureable
proxy for reduced earnings capacity was studied were deemed acceptable
to justify a reduction in the level or duration of ratings for specific
conditions (e.g., time to return to work, activity limitations related
to work, and/or participation restriction(s) from work-related tasks).
Therefore, at this time, VA proposes changes to only two codes
(diagnostic codes 5054 and 5055) where the criteria changes would
result in such a reduction.
I. Proposed Changes to Sec. 4.71a
A. Nomenclature Changes to Existing Diagnostic Codes: 5003, 5012-15,
5023, 5024 and 5242
In its review of the musculoskeletal body system, VA identified a
number of diagnostic codes (DCs) with terms that are outdated or
unclear. As such, it proposes to retitle these DCs to reflect current
medical practice and nomenclature. There are no proposed substantive
changes to the rating criteria for these eight DCs.
VA proposes to retitle DC 5003, currently ``Arthritis, degenerative
(hypertrophic or osteoarthritis)'' as ``Degenerative arthritis, other
than post-traumatic.'' No other language or criteria changes are
proposed for this diagnostic code.
Current DCs 5012 and 5015 refer to ``Bones, new growths of,
malignant'' and ``Bones, new growths of, benign,'' respectively. VA
proposes to replace the term ``new growths of'' in these DCs with the
current medical term, ``neoplasm.'' See S. Terry Canale and James H.
Beaty, Campbell's Operative Orthopedics 859-86 (benign) and 909-45
(malignant) (12th ed. 2013). DC 5012 would be titled ``Bones, neoplasm,
malignant, primary or secondary'' to indicate that both primary and
secondary neoplasms are rated under this DC to ensure consistent and
accurate evaluation. Non-substantive revisions to the language in the
note under DC 5012 are also proposed; specifically, VA proposes to add
the term ``prescribed'' to the phrase ``therapeutic procedure'' to
ensure that readers understand VA will only consider medically-directed
therapy when rating DC 5012.
VA proposes to rename DC 5013, which refers to ``Osteoporosis, with
joint manifestations,'' as ``Osteoporosis, residuals of.'' VA proposes
a similar revision to current DC 5014 by renaming ``Osteomalacia'' as
``Osteomalacia, residuals of.'' Both osteoporosis and osteomalacia, in
and of themselves, do not have any disabling characteristics. See
Kelley's Textbook of Rheumatology 1730-1750 (Gary S. Firestein and
Ralph C. Budd et al. eds.,10th ed. 2017). Rather, it is the residuals
of these conditions that VA evaluates. Thus, adding the reference
``residuals of'' provides more accurate instruction and information to
rating personnel.
Current DC 5023 refers to ``Myositis ossificans.'' VA proposes to
update this DC to reflect the latest medical terminology and rename DC
5023 as ``Heterotopic ossification.'' See Essentials of Physical
Medicine and Rehabilitation: Musculoskeletal Disorders, Pain and
Rehabilitation, 691-95 (Walter R. Frontera and Julie K. Silver et al.
eds., 2d ed. 2008). Additionally, VA proposes to revise DC 5024,
currently named, ``Tenosynovitis,'' to ``Tenosynovitis, tendinitis,
tendinosis, or tendinopathy.'' These newly-added conditions are
commonly seen in the veteran population and represent similar forms of
disability. See Kelley's Textbook of Rheumatology, supra at 587-604.
This update would assist rating personnel in more quickly identifying
the appropriate DC. Non-substantive revisions to the criteria of DC
5024 are also proposed.
Finally, VA proposes to retitle DC 5242, ``Degenerative arthritis
of the spine'' as ``Degenerative arthritis, degenerative disc disease
other than intervertebral disc syndrome.'' This change gives rating
personnel clear guidance whenever they encounter a diagnostic imaging
report that references degenerative disc disease without mention of
intervertebral disc syndrome (also known as disc herniation). A non-
substantive revision to the citation accompanying DC 5242 is also
proposed.
B. Substantive Revisions to Existing Diagnostic Codes: 5002, 5009-5011,
5051-5056, 5120, 5160, 5170, 5201, 5202, 5255, 5257, 5262, and 5271
In addition to modernizing the names of certain DCs, VA also
proposes substantive (i.e., not related to nomenclature) revisions to a
number of existing DCs, to include some instances of changes in the
evaluation criteria.
1. Diagnostic Code 5002
The first substantive revision proposed for Sec. 4.71a involves DC
5002, ``Arthritis rheumatoid (atrophic) As an active process.'' VA
proposes to retitle this code as ``Multi-joint arthritis (except post-
traumatic and gout), 2 or more joints, as an active process.'' VA
proposes this change to include a greater number of systemic arthritis
processes that cause multisystem effects besides rheumatoid arthritis.
The title would employ the phrase ``multi-joint'' rather than
``polyarthritis'' because polyarthritis requires 4 or more joints to
[[Page 35721]]
be involved. VA would provide, in Note (1), a non-exhaustive list of
conditions rated under this code (rheumatoid arthritis, psoriatic
arthritis, spondyloarthropathies, etc.). See Kelley's Textbook of
Rheumatology, supra at 615-616. VA would also remove the language
currently in DC 5002 regarding chronic residuals and, in Note (2),
provide a directive to rate chronic residuals under DC 5003. VA
proposes this change because the current language used for chronic
residuals in DC 5002 is very similar to DC 5003 and its removal would
simplify the schedule. Finally, VA would redesignate the code's current
note as Note (3) and add a prohibition that prevents combining ratings
from active process with DC 5003, instead directing rating personnel to
assign the higher evaluation.
2. Diagnostic Code 5009
VA proposes that diagnostic code 5009, currently titled
``Arthritis, other types (specify),'' be retitled as ``Other specified
forms of arthropathy (excluding gout).'' VA proposes this change to
capture other disease processes that cause joint injury, but are not
necessarily captured within the rating schedule. The current language
accompanying DC 5009, concerning how to rate diagnostic codes 5004-
5009, would be redesignated as Note (2) and would be revised to give
guidance on how to rate both acute phase and chronic residuals. A new
Note (1) would provide a non-exhaustive list of conditions that should
be rated under this diagnostic code. No other changes are proposed for
this code.
3. Diagnostic Code 5010
Diagnostic code 5010 currently states: ``Arthritis, due to trauma,
substantiated by X-ray findings: Rate as arthritis, degenerative.'' VA
proposes to change the title and criteria to ``Post-traumatic
arthritis: Rate as limitation of motion, dislocation, or other
specified instability under the affected joint. If there are 2 or more
joints affected, each rating shall be combined in accordance with Sec.
4.25.'' VA proposes the title change to distinguish between joint
conditions arising from traumatic causes and joint conditions resulting
from systemic processes. This distinction is important, as the natural
history (and ultimately the severity of disability) differs between
joint conditions stemming from trauma as opposed to joint conditions
related to systemic processes.
VA proposes the change in criteria to provide a more accurate
approach to rating joint injuries resulting from trauma. The trauma
process is a different event for each affected joint, as opposed to a
condition such as rheumatoid arthritis, where the same systemic process
can affect more than one joint in the same manner. VA also proposes the
directive to combine ratings for separate joints affected by traumatic
injury in accordance with Sec. 4.25 so there will be no
misunderstanding for rating personnel when encountering this situation.
It is important to note that, as a result of these changes, DC 5010
would no longer rate joints affected by trauma-related arthritis under
the criteria of DC 5003.
4. Diagnostic Code 5011
The next proposed substantive revision to Sec. 4.71a is DC 5011,
currently named ``Bones, caisson disease of.'' VA proposes to first
revise the title of this DC to ``Decompression illness'' to ensure use
of the most modern terminology. See Richard D. Vann et al.,
``Decompression Illness,'' 377 Lancet 153-64 (2010). VA also proposes
to revise the rating criteria for DC 5011, which currently direct
rating personnel to ``Rate as arthritis, cord involvement, or deafness,
depending on the severity of disabling manifestations.'' The proposed
changes would provide more detailed instructions on how to rate
manifestations associated with decompression illness that are outside
of the musculoskeletal system (i.e., not arthritic). It is well
established among medical experts that the most common residual
manifestations from decompression illness involve the vestibule-
cochlear system (e.g., hearing impairment, dizziness, vertigo),
respiratory system (e.g., obstructive lung disease, pulmonary blebs) or
neurologic system (e.g., peripheral neuropathy, stroke, paralysis). As
such, VA proposes to direct rating personnel to consider evaluations
within the auditory system for vestibular residuals, the respiratory
system for pulmonary barotrauma residuals, and the neurologic system
for cerebrovascular accident residuals. Id.
5. Diagnostic Codes 5051-5056
Since the last revision to the musculoskeletal system schedule, the
medical community has been employing a new treatment approach, joint
resurfacing, for selected joints (particularly the hip and knee). There
are important similarities between joint resurfacing and prosthetic
joint replacement. Joint resurfacing takes about the same time to
perform and the recovery/rehabilitation periods are similar to
comparable prosthetic joint replacement. This means that the impact on
earnings capacity caused by the convalescence and rehabilitation from
joint resurfacing is comparable to prosthetic joint replacement.
However, there are significant differences with joint resurfacing,
including: (1) Joint resurfacing preserves more of the original
anatomy; and, (2) in most cases, joint resurfacing restores more of the
original joint function than the prosthetic joint replacement.
Therefore, less residual disability typically results from joint
resurfacing as compared to prosthetic joint replacement. Currently, VA
does not compensate for the disability associated with joint
resurfacing, despite the similar impact on earnings capacity as
prosthetic joint replacement.
To rectify this disparity, VA proposes to incorporate joint
resurfacing within DCs 5054 and 5055 (hip and knee replacement,
respectively), since more research assessing convalescence,
rehabilitation, and functional recovery concerns these two joints. The
DC titles would be revised to incorporate resurfacing, and the 100
percent evaluation for prosthetic hip and knee replacement would also
apply to resurfacing these two joints. However, after the 100 percent
evaluation period ends, further evaluation would assess the limitation
of motion DCs for the hip and knee, rather than the prosthetic joint
replacement of either the hip or knee, because, as previously stated,
there is less of an expectation of residual disability with joint
resurfacing. A note would be added to DCs 5054 and 5055 directing
rating personnel, at the conclusion of the 100 percent evaluation
period, to evaluate hip joint resurfacing claims under DCs 5250-5255
and knee joint resurfacing claims under DCs 5256-5262.
VA currently evaluates total joint replacements by assigning a 100
percent evaluation for 1 year following implantation of a prosthesis.
After 1 year, VA assigns a minimum evaluation, with higher evaluations
for complications or residuals such as weakness, pain, and limitation
of motion. The evaluations assigned under these DCs are intended to
encompass all musculoskeletal residuals under Sec. 4.71a. Separate
evaluations may be assigned for residuals such as scars or neurological
deficits pursuant to Sec. 4.14.
VA proposes two modifications in this regard. First, a note prior
to DCs 5051 to 5056 would clarify that separate evaluations may not be
assigned under Sec. 4.71a for the joint that was resurfaced or
replaced by a prosthesis unless otherwise directed. This note is
intended to clarify current practice and ensure consistent application
of these DCs among rating personnel.
[[Page 35722]]
In addition, for DCs 5054 and 5055, VA proposes to reduce the 100
percent evaluation period from 1 year to 4 months. Current medical
practice for these conditions has recovery timelines that in most cases
permit return to work well short of 1 year. In a review of studies
looking at factors affecting return to work, the average time for
return to work was between 1.1 and 13.9 weeks for hip arthroplasty and
between 8.0 and 12.0 weeks for knee arthroplasty. See Claire Tilbury et
al., ``Return to work after total hip and knee arthroplasty: a
systematic review,'' 53 Rheumatology 512-525 (2014).
6. Diagnostic Code 5120
VA currently evaluates amputations of the arm that involve
disarticulation under DC 5120 as 90 percent disabling regardless of
dominant arm involvement At the outset, VA proposes to revise the name
of this DC to ``Complete amputation, upper extremity,'' as this is a
more accurate description of the amputation level and site.
Second, VA proposes to create two levels of disability under DC
5120 for rating purposes. One level would be titled ``Disarticulation
(involving complete removal of the humerus only)'' and would provide a
90 percent compensation level for either major or minor extremity
involvement; this level would be consistent with the current
compensation level under DC 5120. However, the second level, to be
titled ``Forequarter amputation (involving complete removal of the
humerus along with any portion of the scapula, clavicle, and/or
ribs),'' would provide for 100 percent compensation for either dominant
or non-dominant extremity involvement. See Canale, supra at 659-71.
Although both levels represent complete amputation of the upper
extremity, VA believes a higher level of compensation is warranted for
forequarter amputation because it is a more extensive amputation than
disarticulation and results in a more significant occupational impact.
7. Diagnostic Code 5160
For reasons similar to those discussed immediately above, VA
proposes two revisions of DC 5160, which pertains to amputation of the
thigh at the level of disarticulation with loss of extrinsic pelvic
girdle muscles. First, VA proposes to retitle this DC to ``Complete
amputation, lower extremity'' to more accurately describe the
amputation level and site.
VA also proposes to create two levels of criteria for rating
purposes. One would be titled ``Disarticulation (involving complete
removal of the femur and intrinsic pelvic musculature only)'' and would
provide a 90 percent rating that is consistent with the current rating
under DC 5160. The second level, titled ``Trans-pelvic amputation
(involving complete removal of the femur and intrinsic pelvic
musculature along with any portion of the pelvic bones),'' would
provide for a 100 percent rating. See Canale, supra at 651-58. VA
believes that a higher level of compensation is warranted for trans-
pelvic amputation because it is a more extensive amputation than
disarticulation and results in a more significant occupational impact.
VA also proposes to insert a note under DC 5160 directing rating
personnel to separately evaluate residuals involving other body
systems, such as bowel or bladder impairment, under the appropriate
diagnostic code.
8. Diagnostic Code 5170
Current DC 5170 refers to ``Toes, all, amputation of, without
metatarsal loss.'' VA proposes to add the phrase ``or transmetatarsal,
amputation of, with up to half of metatarsal loss'' to include a
residual of toe amputation that causes similar disability. See Canale,
supra at 622-23. No change to the current level of compensation is
proposed.
9. Diagnostic Code 5201
VA currently assigns ratings for limitation of motion of the arm at
the shoulder where motion is limited to 25 degrees from the side, 45
degrees (midway between the side and shoulder level), or 90 degrees (at
the shoulder level).
VA proposes to clarify the terminology used in these criteria by
adding ranges of motion of the shoulder. Specifically, VA proposes to
assign a 40 percent rating for a major joint, or 30 percent for a minor
joint, where flexion and/or abduction is limited to 25 degrees from the
side. VA also proposes to assign a 30 percent rating for a major joint,
or 20 percent for a minor joint, where motion is limited to ``midway
between side and shoulder level,'' defined as flexion and/or abduction
limited to 45 degrees or less. Finally, VA proposes to assign a 20
percent rating for a major or minor joint where motion is limited ``at
shoulder level,'' defined as flexion and/or abduction limited to 90
degrees or less.
These changes are not intended to alter the rating criteria. The
proposed changes simply clarify the specific ranges of motion that
qualify as limitations to ensure rating personnel consistently apply
these criteria.
10. Diagnostic Code 5202
Currently, VA assigns a 20 percent rating for either shoulder joint
when there are infrequent episodes of dislocation of the humerus at the
scapulohumeral joint, with guarding of movement only at the shoulder
level. VA proposes to define ``the shoulder level'' as flexion and/or
abduction at 90 degrees. This change is not intended to alter the
rating criteria. The proposed change simply clarifies the specific
ranges of motion that qualify as limitations to ensure rating personnel
consistently apply these criteria.
11. Diagnostic Code 5255
VA currently evaluates malunion of the femur by assigning a 30
percent rating for a ``marked knee or hip disability,'' a 20 percent
rating for a ``moderate knee or hip disability,'' and a 10 percent
rating for a ``slight knee or hip disability.'' These criteria are
subjective and the terminology is vague, resulting in inconsistent
ratings.
Therefore, VA proposes removing this terminology and replacing it
with an instruction to rate malunion of the femur as a knee or hip
disability, whichever is predominant, under existing DCs that contain
objective criteria. Specifically, this condition may be rated under DCs
5256 (Knee, ankylosis of), 5257 (Knee, other impairment of), 5260 (Leg,
limitation of flexion of), 5261 (Leg, limitation of extension of), 5250
(Hip, ankylosis of), 5251 (Thigh, limitation of extension of), 5252
(Thigh, limitation of flexion of), 5253 (Thigh, impairment of), or 5254
(Hip, flail joint). This change would ensure that rating personnel
consistently evaluate this disability based on objective criteria.
12. Diagnostic Code 5257
VA currently assigns ratings for recurrent subluxation or lateral
instability of the knee based on whether the condition is slight (10
percent), moderate (20 percent), or severe (30 percent). These criteria
are subjective and the terminology is vague, resulting in VA assigning
inconsistent ratings.
When the condition involves patellar instability of the knee (due
to recurrent patellar subluxation or patellar dislocation), one can
determine the severity of functional impairment in large part by 1) the
presence, or absence of, anatomic abnormalities (e.g., direct damage to
patellofemoral ligament complex, ``flake'' fractures, or abnormalities
affecting the patella and/or femoral trochlea); and 2) whether
conservative treatment prevents recurrent instability. See Alexis C.
[[Page 35723]]
Colvin and Robin V. West, ``Current Concepts Review: Patellar
Instability,'' J. Bone & Joint Surgery--Am. Volume 90: 2751-62 (2008).
Instability or laxity of the knee that involves other stabilizing
structures of the knee such as the collateral ligaments (medial or
lateral) or the cruciate ligaments (anterior or posterior) are given a
``grade'' depending upon the amount of translation, in millimeters, of
the joint (e.g., a grade 1 injury of the posterior cruciate ligament
(PCL) is represented by 0 to 5 millimeters (mm) of translation). T. K.
Kakarlapudi et al., ``Knee instability: isolated and complex,'' 34 Br.
J. Sports Med. 395-400 (2000). Resulting functional impairment depends
upon the grade of the injury and whether surgical intervention is
required. Id. The higher the number grade is, the more severe the
injury; that is, grade 1 would represent the least severe injury, grade
2 would be a more severe injury, and grade 3 would be the most severe
injury.
Therefore, VA proposes replacing the current subjective terms with
the following objective criteria: a 30 percent rating would be assigned
for persistent grade 3 instability despite operative intervention and
for which ambulation requires both bracing and an assistive device
(e.g., cane(s), crutch(es), or a walker), as prescribed by a physician;
or, in the case of patellar instability, persistent instability despite
surgical repair (whether after the primary subluxation/dislocation
event or due to recurrent instability). A 20 percent would be assigned
for persistent grade 3 instability without operative intervention, but
when ambulation requires both bracing and an assistive device (e.g.,
cane(s), crutch(es), or a walker), as prescribed by a physician; or, in
the case of patellar instability, recurrent instability persists due to
one or more documented underlying anatomic abnormalities, without
surgical repair. A 10 percent evaluation would be assigned for
persistent grade 1, 2, or 3 instability which requires an ambulation
assistive device or bracing, as prescribed by a physician; or, in the
case of patellar instability, recurrent instability persists without
documented underlying anatomic abnormalities, without surgical repair.
These criteria would take into account both the grade of the injury, as
well as functional impairment resulting from the injury.
VA also proposes a note defining the grading of instability. Note
(1) would specify that grade 1 instability requires 0-5 mm of joint
translation, while grade 2 requires translation of 6-10 mm, and grade 3
requires joint translation equal to or greater than 11 mm. These levels
of instability or laxity are based upon modern medical practice. See
Campbell's Operative Orthopedics, supra at 2157.
VA proposes a second note to clarify what constitutes surgical
repair of patellar instability. Note (2) would specify that any
operative procedure which does not involve actual anatomical structural
repair would not qualify as surgical repair for the purposes of
compensation. This note is specifically designed to exclude procedures
that are not designed to repair instability or subluxation, such as
joint aspiration, arthroscopy to remove loose bodies, and so forth.
In addition, DC 5257 currently refers to ``lateral instability.''
Under current practice, any instability or laxity of the knee is
evaluated under this code. Therefore, VA proposes to remove the term
``lateral,'' so that this code also encompasses other specified forms
of instability and/or laxity.
13. Diagnostic Code 5262
VA currently rates malunion of the tibia and fibula by assigning a
30 percent rating for a ``marked knee or ankle disability,'' a 20
percent rating for a ``moderate knee or ankle disability,'' and a 10
percent rating for a ``slight knee or ankle disability.'' These
criteria are subjective and the terminology is vague. This results in
rating personnel assigning inconsistent ratings under these criteria.
Therefore, VA proposes removing this terminology and replacing it
with an instruction to rate malunion of the tibia or fibula as a knee
or ankle disability, whichever is predominant, under existing DCs that
contain objective criteria. Specifically, this condition may be
evaluated under DCs 5256 (Knee, ankylosis of), 5257 (Knee, other
impairment of), 5260 (Leg, limitation of flexion of), 5261 (Leg,
limitation of extension of), 5270 (Ankle, ankylosis of), or 5271
(Ankle, limited motion of). This change would ensure that rating
personnel consistently assign evaluations based on objective criteria.
Another condition commonly claimed for disability compensation is
medial tibial stress syndrome (MTSS), also known as ``shin splints.''
It is a benign but painful condition that is typically diagnosed simply
by history and physical examination, though imaging studies such as
plain radiographs, bone scans, or magnetic resonance imaging (MRI) can
be used in borderline cases, as well as to diagnose other conditions.
The vast majority of cases respond to conservative therapy, such as
rest, shock-absorbing insoles, and electrowave shock therapy. The rare
persistent cases that do not respond to conservative treatment can be
treated with surgical intervention. To that end, VA proposes to modify
the criteria for DC 5262 to account for MTSS as well as associated
conditions. See M. Reshef and D. Guelich, ``Medial Tibial Stress
Syndrome,'' 31 Clinical Sports Med. 273-90 (2012).
14. Diagnostic Code 5271
VA currently assigns ratings for limited motion of the ankle
depending upon whether the limitation is moderate (10 percent) or
marked (20 percent). These criteria are subjective and the terminology
is vague, resulting in inconsistent evaluations.
Therefore, VA proposes to define marked limitation of motion as
less than 5 degrees dorsiflexion or less than 10 degrees plantar
flexion. VA also proposes to define moderate limitation of motion as
less than 15 degrees dorsiflexion or less than 30 degrees plantar
flexion. As VA currently uses these standards to define marked and
moderate, this change is intended as a clarification of current policy
and would ensure consistent application of these criteria among rating
personnel.
C. Proposed New Diagnostic Codes
1. Diagnostic Code 5244
The current Rating Schedule does not provide instructions for
rating complete traumatic paralysis, i.e., paraplegia or quadriplegia;
however, this disability is not uncommon in the veteran population. As
such, VA proposes the addition of DC 5244, ``Traumatic paralysis,
complete.''
The proposed criteria for DC 5244 would direct personnel to rate
paraplegia, or functional loss of the lower limbs and trunk, under DC
5110. DC 5110 applies to loss of use of both feet and provides for a
100 percent disability rating with entitlement to special monthly
compensation. Proposed DC 5244 would also provide instructions for
rating quadriplegia, or paralysis of all four limbs (i.e., the entire
body below the neck). Specifically, VA proposes to rate quadriplegia
under both DC 5109, loss of use of both hands, and DC 5110, loss of use
of both feet, and combine. In practice, a veteran with service-
connected quadriplegia would be entitled to two 100 percent ratings,
which combine under 38 CFR 4.25 to a total evaluation of 100 percent.
The veteran would also be entitled to special monthly compensation.
2. Diagnostic Code 5285
VA currently evaluates foot injuries not specifically listed in
Sec. 4.71a under
[[Page 35724]]
DC 5284 as ``Foot injuries, other.'' Plantar fasciitis, a foot
disability seen in the veteran population, is generally rated under
this DC. However, unlike other unlisted foot injuries and conditions,
which can often result in a variety of signs and symptoms with varying
degrees of disability, plantar fasciitis, and its functional effects,
are very well defined. See Sports Medicine and Arthroscopic Surgery of
the Foot and Ankle 83-93 (Amol Saxena ed., 2013). Plantar fasciitis,
also known as ``jogger's heel,'' is generally characterized by heel
pain due to inflammation. Craig C. Young et al., ``Plantar fasciitis,''
Medscape Reference (Feb. 4, 2014), http://emedicine.medscape.com/article/86143-overview (last visited April 15, 2014). However, even at
its most severe, this condition involves an otherwise structurally
intact foot.
There are a variety of both surgical and non-surgical treatments
that may relieve the primary symptoms of plantar fasciitis.
Conservative measures are always employed first, and frequently include
icing, stretching, non-steroidal anti-inflammatory drug (NSAID)
therapy, strapping and taping, and/or over-the-counter orthotics. Id.
at http://emedicine.medscape.com/article/86143-treatment. Other
nonsurgical treatments may include injections, physical therapy, and
custom orthotics. Id. Studies have reported a resolution incidence of
up to 90 percent with nonsurgical measures. Id. In severe cases, non-
surgical measures fail and surgery is required.
Individuals who respond to treatment, whether surgical or non-
surgical, have generally no more than slight functional limitation due
to plantar fasciitis. Further, such limitation is more associated with
the treatment(s) required to check the pain (e.g., limitation of
physical activities (such as running), injections, icing, use of
NSAIDS, surgical residuals, etc.) than with the actual disability
itself. For individuals who do not respond to treatment, the resulting
limitations may vary, but are generally more pronounced for those who
have bilateral, rather than unilateral, plantar fasciitis.
Given the foregoing, VA proposes to create a new DC, namely DC
5285, ``Plantar fasciitis,'' to rate this condition. VA intends to
evaluate this disability based on a combination of extent (one foot or
both feet) and response to treatment (responsive or nonresponsive). For
individuals whose plantar fasciitis does not respond to both surgical
and non-surgical treatment, VA proposes to award 30 percent disability
rating if both feet are affected and a 20 percent disability rating if
one foot is affected. For an individual whose plantar fasciitis (either
unilateral or bilateral) is responsive to treatment (either non-
surgical or surgical), VA proposes a 10 percent disability rating.
Finally, consistent with other foot injuries and disabilities, VA
intends to include a note with DC 5285 that would instruct rating
personnel to assign a 40 percent rating in cases where there is actual
loss of use of the foot. In cases where a veteran's bilateral plantar
fasciitis has not improved following surgery and there is actual loss
of use of one foot, this would result in a 40 percent evaluation for
that foot and a 20 percent evaluation for the other foot that was not
responsive to treatment, but did not result in loss of use.
D. Removal of Existing Diagnostic Codes
VA proposes to remove three obsolete codes from Sec. 4.71a. The
first two, DC 5018 and DC 5020, refer to ``Hydrarthrosis,
intermittent'' and ``Synovitis,'' respectively. Both hydrarthrosis and
synovitis are signs found on physical examination. The disability from
a specific condition that causes either hydrarthrosis or synovitis
(e.g., rheumatoid arthritis, psoriatic arthritis, or pseudogout) is
captured within current evaluation criteria for the specific disabling
condition. See Kelley's Textbook of Rheumatology, supra at 588. Given
that VA's disability compensation system is designed to compensate for
disabilities, it is not appropriate to list either sign as its own DC.
For similar reasons, VA proposes to remove DC 5022,
``Periostitis.'' Current medical terminology refers to ``periosteal
reaction'' in order to include all of the possible causes, such as
bleeding, infection, or tumor. In contrast, ``periostitis'' refers to a
non-specific inflammatory process due to a number of diagnoses that
could potentially result in service connection. Since an evaluation
should be conducted under the primary diagnosis, rather than a
radiographic finding such as periostitis, VA intends to remove DC 5022.
See Radiologic-Pathologic Correlations from Head to Toe: Understanding
the Manifestations of Disease 668 (Nicholas C. Gourtsoyiannis and Pablo
R. Ros eds., 2005).
II. Proposed Changes to Sec. 4.73
Section 4.73 provides VA's schedule for rating muscle injuries.
Following its review of this body system, VA proposes the addition of
two DCs for conditions that previously required analogous rating.
The first proposed code, DC 5330, would apply to residuals of
rhabdomyolysis, in which muscle tissue breaks down rapidly. See Janice
L. Zimmerman and Michael C. Shen, ``Rhabdomyolysis,'' 144(3) CHEST
1058-65 (2013). Although VA proposes to rate this condition based on
residual impairment to the affected muscle group(s), it believes that a
specific DC is needed as there is no current instruction to rating
personnel as to how to evaluate this condition. Furthermore, in
addition to provide rating instructions to evaluate each affected
muscle group, VA proposes to include a note directing rating personnel
to separately evaluate any chronic renal complications that may be
associated with this condition.
The second DC VA proposes to add to Sec. 4.73 is DC 5331,
``Compartment syndrome.'' Similar to DC 5330, VA proposes to rate
compartment syndrome, a condition in which there is increased pressure
within the muscles, according to the affected muscle group(s). See
Canale, supra at 2311-21. The addition of this DC would provide clear
instructions to rating personnel; it would also eliminate the need for
analogous coding for a condition seen in the veteran population.
In addition, VA proposes to add a second note at the beginning of
Sec. 4.73 directing that rating personnel consider the objective
criteria contained in Sec. 4.56 when determining whether a muscle
disability is slight, moderate, moderately severe, or severe under DCs
5301 to 5323. Although Sec. 4.56 references these DCs, the levels of
severity are not defined in Sec. 4.73, nor does that section currently
reference Sec. 4.56. Therefore, VA proposes to add this note for a
cross-reference.
Executive Orders 12866 and 13563
Executive Orders 12866 and 13563 direct agencies to assess the
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 effects, and other advantages; distributive impacts;
and equity). Executive Order 13563 (Improving Regulation and Regulatory
Review) emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
Executive Order 12866 (Regulatory Planning and Review) defines a
``significant regulatory action,'' which requires review by the Office
of Management and Budget (OMB), as ``any regulatory action that is
likely to result in a rule that may:
[[Page 35725]]
(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 this Executive
Order.''
VA has examined the economic, interagency, budgetary, legal, and
policy implications of this proposed rule, and it has been determined
not to be a significant regulatory action under Executive Order 12866.
VA's impact analysis can be found as a supporting document at
http://www.regulations.gov, usually within 48 hours after the
rulemaking document is published. Additionally, a copy of the
rulemaking and its impact analysis are available on VA's Web site at
http://www1.va.gov/orpm/, by following the link for ``VA Regulations
Published.''
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 the 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 one year. This proposed rule would have no such
effect on State, local, and tribal governments, or on the private
sector.
Paperwork Reduction Act
Although this document contains provisions constituting a
collection of information under the provisions of the Paperwork
Reduction Act (44 U.S.C. 3501 et seq.), no new or proposed revised
collections of information are associated with this proposed rule. The
information collection requirements are currently approved by the
Office of Management and Budget (OMB) and have been assigned OMB
control numbers 2900-0747, 2900-0776, 2900-0778, and 2900-0802 through
2900-0813. While no modifications to these forms are made by this
rulemaking, the total incremental cost to all respondents is estimated
to be $198,002.21 during the first year. See Regulatory Impact Analysis
for a full explanation.
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 would be exempt from the initial
and final regulatory flexibility analysis requirements of sections 603
and 604.
Catalog of Federal Domestic Assistance Numbers and Titles
The Catalog of Federal Domestic Assistance program numbers and
titles for this rule are 64.013, Veterans Prosthetic Appliances;
64.109, Veterans Compensation for Service-Connected Disability; and
64.110, Veterans Dependency and Indemnity Compensation for Service-
Connected Death.
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. Gina S.
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs,
approved this document on June 20, 2017, for publication.
Dated: July 21, 2017.
Michael Shores,
Director, Regulation Policy & Management, Office of the Secretary,
Department of Veterans Affairs.
List of Subjects in 38 CFR Part 4
Disability benefits, Pensions, Veterans.
For the reasons set out in the preamble, VA proposes to amend 38
CFR part 4 as follows:
PART 4--SCHEDULE FOR RATING DISABILITIES
Subpart B--Disability Ratings
0
1. The authority citation for part 4, subpart B continues to read as
follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
0
2. Amend Sec. 4.71a as follows:
0
a. Revise diagnostic codes 5002, 5003, 5009-5015, 5023-5024, 5054,
5055, 5120, 5160, 5170, 5201, 5202, 5242, 5255, 5257, 5262, and 5271.
0
b. Remove diagnostic codes 5018, 5020, and 5022.
0
c. Add new introduction note to diagnostic codes 5051 through 5056 and
add new diagnostic codes 5244 and 5285.
The revisions and additions read as follows:
Sec. 4.71a Schedule of ratings--musculoskeletal system.
Acute, Subacute, or Chronic Diseases
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
* * * * * * *
5002 Multi-joint arthritis (except post-traumatic and
gout), 2 or more joints, as an active process:
* * * * * * *
One or two exacerbations a year in a well- 20
established diagnosis..............................
Note (1): Examples of conditions rated using this
diagnostic code include, but are not limited to,
rheumatoid arthritis, psoriatic arthritis, and
spondyloarthropathies.
Note (2): For chronic residuals, rate under
diagnostic code 5003.
Note (3): The ratings for the active process will
not be combined with the residual ratings for
limitation of motion, ankylosis, or diagnostic code
5003. Instead, assign the higher evaluation.
5003 Degenerative arthritis, other than post-traumatic:
* * * * * * *
5009 Other specified forms of arthropathy (excluding
gout).
[[Page 35726]]
Note (1): Other specified forms of arthropathy
include, but are not limited to, Charcot
neuropathic, hypertrophic, crystalline, and other
autoimmune arthropathies.
Note (2): With the types of arthritis, diagnostic
codes 5004 through 5009, rate the acute phase under
diagnostic code 5002; rate any chronic residuals
under diagnostic code 5003.
5010 Post-traumatic arthritis: Rate as limitation of
motion, dislocation, or other specified instability
under the affected joint. If there are 2 or more joints
affected, each rating shall be combined in accordance
with Sec. 4.25.
5011 Decompression illness: Rate manifestations under
the appropriate diagnostic code within the affected
body system, such as arthritis for musculoskeletal
residuals; auditory system for vestibular residuals;
respiratory system for pulmonary barotrauma residuals;
and neurologic system for cerebrovascular accident
residuals.
5012 Bones, neoplasm, malignant, primary or secondary... 100
Note: The 100 percent rating will be continued for 1
year following the cessation of surgical, X-ray,
antineoplastic chemotherapy or other prescribed
therapeutic procedure. If there has been no local
recurrence or metastases, rate based on residuals.
5013 Osteoporosis, residuals of.
5014 Osteomalacia, residuals of.
5015 Bones, neoplasm, benign.
* * * * * * *
5023 Heterotopic ossification.
5024 Tenosynovitis, tendinitis, tendinosis or
tendinopathy.
Evaluate the diseases under diagnostic codes 5013
through 5024 as degenerative arthritis, based on
limitation of motion of affected parts. However,
evaluate gout under diagnostic code 5003.
* * * * * * *
------------------------------------------------------------------------
Prosthetic Implants and Resurfacing
------------------------------------------------------------------------
Rating
-------------------------------
Major Minor
------------------------------------------------------------------------
Note: When an evaluation is assigned for joint resurfacing or the
prosthetic replacement of a joint under diagnostic codes 5051-5056, an
additional rating under Sec. 4.71a may not also be assigned for that
joint, unless otherwise directed.
------------------------------------------------------------------------
* * * * * * *
5054 Hip, resurfacing or replacement
(prosthesis)
Prosthetic replacement of the head of
the femur or of the acetabulum:
For 4 months following implantation .............. 100
of prosthesis or resurfacing.......
Note: At the conclusion of the 100
percent evaluation period, evaluate
resurfacing under diagnostic codes
5250 through 5255.
* * * * * * *
5055 Knee, resurfacing or replacement
(prosthesis)
Prosthetic replacement of knee joint:
For 4 months following implantation .............. 100
of prosthesis or resurfacing.......
Note: At the conclusion of the 100
percent evaluation period, evaluate
resurfacing under diagnostic codes
5256 through 5262.
* * * * * * *
------------------------------------------------------------------------
Amputations: Upper Extremity
------------------------------------------------------------------------
Rating
-------------------------------
Major Minor
------------------------------------------------------------------------
Arm, amputation of:
5120 Complete amputation, upper
extremity:
Forequarter amputation 100 100
(involving complete removal of
the humerus along with any
portion of the scapula,
clavicle, and/or ribs).........
Disarticulation (involving 90 90
complete removal of the humerus
only)..........................
* * * * * * *
------------------------------------------------------------------------
Amputations: Lower Extremity
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Thigh, amputation of:
[[Page 35727]]
5160 Complete amputation, lower extremity
Trans-pelvic amputation (involving complete 100
removal of the femur and intrinsic pelvic
musculature along with any portion of the
pelvic bones)..................................
Disarticulation (involving complete removal of 90
the femur and intrinsic pelvic musculature
only)..........................................
Note: Separately evaluate residuals involving
other body systems (e.g., bowel impairment,
bladder impairment) under the appropriate
diagnostic code.
* * * * * * *
5170 Toes, all, amputation of, without metatarsal 30
loss or transmetatarsal, amputation of, with up to
half of metatarsal loss............................
* * * * * * *
------------------------------------------------------------------------
The Shoulder and Arm
------------------------------------------------------------------------
Rating
-------------------------------
Major Minor
------------------------------------------------------------------------
* * * * * * *
5201 Arm, limitation of motion of:
Flexion and/or abduction limited to 40 30
25[deg] from side..................
Midway between side and shoulder 30 20
level (flexion and/or abduction
limited to 45[deg])................
At shoulder level (flexion and/or 20 20
abduction limited to 90[deg])......
5202 Humerus, other impairment of:
Loss of head of (flail shoulder).... 80 70
Nonunion of (false flail joint)..... 60 50
Fibrous union of.................... 50 40
Recurrent dislocation of at .............. ..............
scapulohumeral joint:
With frequent episodes and guarding 30 20
of all arm movements...............
With infrequent episodes, and 20 20
guarding of movement only at
shoulder level (flexion and/or
abduction at 90[deg])..............
Malunion of:
Marked deformity.................... 30 20
Moderate deformity.................. 20 20
* * * * * * *
------------------------------------------------------------------------
The Spine
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
General Rating Formula for Diseases and Injuries of the
Spine
* * * * * * *
5242 Degenerative arthritis, degenerative disc disease
other than intervertebral disc syndrome (also, see
diagnostic code 5003)..................................
* * * * * * *
5244 Traumatic paralysis, complete:
Paraplegia: Rate under diagnostic code 5110.
Quadriplegia: Rate separately under diagnostic codes
5109 and 5110 and combine evaluations in accordance
with Sec. 4.25.
------------------------------------------------------------------------
The Hip and Thigh
------------------------------------------------------------------------
* * * * * * *
5255 Femur, impairment of:
Fracture of shaft or anatomical neck of:
With nonunion, with loose motion (spiral or 80
oblique fracture)..............................
With nonunion, without loose motion, weight 60
bearing preserved with aid of brace............
Fracture of surgical neck of, with false joint.. 60
Malunion of:
Evaluate under diagnostic codes 5256, 5257,
5260, or 5261 for the knee, or 5250-5254 for
the hip, whichever results in the highest
evaluation.
------------------------------------------------------------------------
The Knee and Leg
------------------------------------------------------------------------
* * * * * * *
5257 Knee, other impairment of:
[[Page 35728]]
Recurrent subluxation or instability:
Persistent grade 3 instability despite operative 30
intervention and a physician prescribes both
bracing and assistive device (e.g., cane(s),
crutch(es), or a walker) for ambulation........
Persistent grade 3 instability without operative 20
intervention, and a physician prescribes both
bracing and assistive device (e.g., cane(s),
crutch(es), or a walker) for ambulation........
Persistent grade 1, 2, or 3 instability and a 10
physician prescribes an assistive device (e.g.,
cane(s), crutch(es), or a walker) or bracing
for ambulation.................................
Patellar instability:
With documented surgical repair, persistent 30
instability either after the primary
subluxation/dislocation event or due to
recurrent instability..........................
Without surgical repair, recurrent instability 20
with one or more documented underlying anatomic
abnormalities (e.g., direct damage to
patellofemoral ligament complex, ``flake''
fractures, or abnormalities affecting the
patella and/or femoral trochlea)...............
Without surgical repair, recurrent instability 10
without documented underlying anatomic
abnormalities..................................
Note (1): Grade 1 is defined as 0-5 mm of joint
translation, grade 2 is defined as 6-10 mm of joint
translation, and grade 3 is defined as joint
translation of equal to or greater than 11 mm.
Note (2): For patellar instability, a surgical
procedure that does not involve repair of one or
more anatomic structures that contribute to the
underlying instability shall not qualify as
surgical repair for compensation purposes
(including, but not limited to, arthroscopy to
remove loose bodies and joint aspiration).
* * * * * * *
5262 Tibia and fibula, impairment of:
Nonunion of, with loose motion, requiring brace..... 40
Malunion of:
Evaluate under diagnostic codes 5256, 5257,
5260, or 5261 for the knee, or 5270 or 5271 for
the ankle, whichever results in the highest
evaluation.
Medial tibial stress syndrome (MTSS), or shin
splints:
With imaging evidence (X-rays, bone scan, or 30
MRI), requiring treatment for no less than 12
consecutive months and unresponsive to shoe
orthotics, other conservative treatment, or
surgery, both lower extremities................
With imaging evidence (X-rays, bone scan, or 20
MRI), requiring treatment for no less than 12
consecutive months, and unresponsive to shoe
orthotics, other conservative treatment, or
surgery, one lower extremity...................
With imaging evidence (X-rays, bone scan, or 10
MRI), requiring treatment for no less than 12
consecutive months, and unresponsive to both
shoe orthotics and other conservative
treatment, one or both lower extremities.......
Treatment less than 12 consecutive months, one 0
or both lower extremities......................
* * * * * * *
------------------------------------------------------------------------
The Ankle
------------------------------------------------------------------------
* * * * * * *
5271 Ankle, limited motion of:
Marked (less than 5 degrees dorsiflexion or less 20
than 10 degrees plantar flexion)...................
Moderate (less than 15 degrees dorsiflexion or less 10
than 30 degrees plantar flexion)...................
* * * * * * *
------------------------------------------------------------------------
The Foot
------------------------------------------------------------------------
* * * * * * *
5285 Plantar fasciitis:
With symptoms not relieved by both non-surgical and
surgical treatment:
bilateral....................................... 30
unilateral...................................... 20
With symptoms relieved by either non-surgical or 10
surgical treatment, unilateral or bilateral........
Note: With actual loss of use of the foot, rate 40
percent.
------------------------------------------------------------------------
The Skull
------------------------------------------------------------------------
* * * * * * *
------------------------------------------------------------------------
(Authority: 38 U.S.C. 1155)
* * * * *
0
3. In Sec. 4.73, add new introduction notes (1) and (2) and add new
diagnostic codes 5330 and 5331 to read as follows:
Sec. 4.73 Schedule of ratings--muscle injuries.
Note (1): When evaluating any claim involving muscle injuries
resulting in loss of use of any extremity or loss of use of both
buttocks (diagnostic code 5317, Muscle Group XVII), refer to Sec.
3.350 of this chapter to determine whether the veteran may be
entitled to special monthly compensation.
Note (2): Ratings of slight, moderate, moderately severe, or
severe for diagnostic
[[Page 35729]]
codes 5301 through 5323 will be determined based upon the criteria
contained in Sec. 4.56.
* * * * *
Miscellaneous
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
* * * * * * *
5330 Rhabdomyolysis, residuals of.
Rate each affected muscle group separately and
combine in accordance with Sec. 4.25.
Note: Separately evaluate any chronic renal
complications within the appropriate body system.
5331 Compartment syndrome.
Rate each affected muscle group separately and
combine in accordance with Sec. 4.25.
------------------------------------------------------------------------
(Authority: 38 U.S.C. 1155)
0
4. Amend Appendix A to Part 4 as follows:
0
a. In Sec. 4.71a, revise diagnostic codes 5002, 5003, 5012, 5024,
5051-5056, 5255, 5257;
0
b. In Sec. 4.71a, add diagnostic codes 5009-5011, 5013-5015, 5018,
5020, 5022-5023, 5120, 5160, 5170, 5201, 5202, 5242, 5244, 5262, 5271
and 5285;
0
c. In Sec. 4.73, add new introduction note and diagnostic codes 5330
and 5331.
The revisions read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946
------------------------------------------------------------------------
Diagnostic Code
Sec. No.
------------------------------------------------------------------------
4.71a
* * * * * * *
5002 Evaluation March 1,
1963; title,
criteria, note
[insert effective
date of final rule]
5003 Added July 6, 1950;
title [insert
effective date of
final rule]
* * * * * * *
5009 Title, evaluation,
note [insert
effective date of
final rule].
5010 Title, criteria
[insert effective
date of final rule].
5011 Title, criteria
[insert effective
date of final rule].
5012 Criterion March 10,
1976; title, note
[insert effective
date of final rule].
5013 Title [insert
effective date of
final rule].
5014 Title [insert
effective date of
final rule].
5015 Title [insert
effective date of
final rule].
5018 Removed [insert
effective date of
final rule].
5020 Removed [insert
effective date of
final rule].
5022 Removed [insert
effective date of
final rule].
5023 Title [insert
effective date of
final rule].
5024 Criterion March 1,
1963; title, criteria
[insert effective
date of final rule].
* * * * * * *
5051 Added September 22,
1978; note [insert
effective date of
final rule].
5052 Added September 22,
1978; note [insert
effective date of
final rule].
5053 Added September 22,
1978; note [insert
effective date of
final rule].
5054 Added September 22,
1978; title,
criterion, and note
[insert effective
date of final rule].
5055 Added September 22,
1978; title,
criterion, and note
[insert effective
date of final rule].
5056 Added September 22,
1978; note [insert
effective date of
final rule].
* * * * * * *
5120 Title, criterion
[insert effective
date of final rule].
5160 Title, criterion, note
[insert effective
date of final rule].
* * * * * * *
5170 Title [insert
effective date of
final rule].
* * * * * * *
5201 Criterion [insert
effective date of
final rule].
5202 Criterion [insert
effective date of
final rule].
* * * * * * *
5242 Title [insert
effective date of
final rule]
* * * * * * *
5244 Added [insert
effective date of
final rule].
[[Page 35730]]
* * * * * * *
5255 Criterion July 6,
1950; criterion
[insert effective
date of final rule].
* * * * * * *
5257 Evaluation July 6,
1950; criterion and
note [insert
effective date of
final rule].
* * * * * * *
5262 Criterion [insert
effective date of
final rule].
* * * * * * *
5271 Criterion [insert
effective date of
final rule].
* * * * * * *
5285 Added [insert
effective date of
final rule].
* * * * * * *
4.73........................... ............... Introduction NOTE
criterion July 3,
1997; second NOTE
added [insert
effective date of
final rule].
* * * * * * *
5330 Added [insert
effective date of
final rule].
5331 Added [insert
effective date of
final rule].
------------------------------------------------------------------------
0
5. Amend Appendix B to Part 4 as follows:
0
a. Revise diagnostic codes 5002, 5003, 5009-5015, 5023, 5024, 5054,
5055, 5120, 5160, 5170 and 5242;
0
b. Add diagnostic codes 5244, 5285, 5330, and 5331; and
0
c. Remove diagnostic codes 5018, 5020 and 5022.
The revisions read as follows:
Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic Code No.
------------------------------------------------------------------------
THE MUSCULOSKELETAL SYSTEM
Acute, Subacute, or Chronic Diseases
------------------------------------------------------------------------
* * * * * * *
5002.............................. Multi-joint arthritis (except post-
traumatic and gout), 2 or more
joints, as an active process.
5003.............................. Degenerative arthritis, other than
post-traumatic.
* * * * * * *
5009.............................. Other specified forms of arthropathy
(excluding gout).
5010.............................. Post-traumatic arthritis.
5011.............................. Decompression illness.
5012.............................. Bones, neoplasm, malignant, primary
or secondary.
5013.............................. Osteoporosis, residuals of.
5014.............................. Osteomalacia, residuals of.
5015.............................. Bones, neoplasm, benign.
* * * * * * *
5023.............................. Heterotopic ossification.
5024.............................. Tenosynovitis, tendinitis,
tendinosis or tendinopathy.
* * * * * * *
5054.............................. Hip, resurfacing or replacement
(prosthesis).
5055.............................. Knee, resurfacing or replacement
(prosthesis).
* * * * * * *
------------------------------------------------------------------------
AMPUTATIONS: UPPER EXTREMITY
------------------------------------------------------------------------
Arm, amputation of:
5120.......................... Complete amputation, upper
extremity.
* * * * * * *
------------------------------------------------------------------------
AMPUTATIONS: LOWER EXTREMITY
------------------------------------------------------------------------
Thigh, amputation of:
5160.......................... Complete amputation, lower
extremity.
[[Page 35731]]
* * * * * * *
5170.......................... Toes, all, amputation of, without
metatarsal loss or transmetatarsal,
amputation of, with up to half of
metatarsal loss.
* * * * * * *
------------------------------------------------------------------------
SPINE
------------------------------------------------------------------------
* * * * * * *
5242.............................. Degenerative arthritis, degenerative
disc disease other than
intervertebral disc syndrome (also,
see either 5003 or 5010).
* * * * * * *
5244.............................. Traumatic paralysis, complete.
* * * * * * *
------------------------------------------------------------------------
THE FOOT
------------------------------------------------------------------------
* * * * * * *
5285.............................. Plantar fasciitis.
* * * * * * *
------------------------------------------------------------------------
MUSCLE INJURIES
------------------------------------------------------------------------
* * * * * * *
------------------------------------------------------------------------
Miscellaneous
------------------------------------------------------------------------
* * * * * * *
5330.............................. Rhabdomyolysis, residuals of.
5331.............................. Compartment syndrome.
* * * * * * *
------------------------------------------------------------------------
0
6. Amend Appendix C to Part 4 as follows:
0
a. Revise the entries for Amputation, Arthritis, New growths, Myositis
ossificans, Tenosynovitis, Prosthetic Implants, and Hip;
0
b. Add entries in alphabetical order for Spine, Traumatic paralysis,
complete; Plantar fasciitis; Rhabdomyolysis; and Compartment syndrome;
and
0
c. Remove entries for Hydroarthrosis, intermittent; Synovitis; and
Periostitis.
The revisions read as follows:
Appendix C to Part 4--Alphabetical Index of Disabilities
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Diagnostic
Code No.
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* * * * * * *
Amputation:
Arm:
Complete amputation, upper extremity............ 5120
Above insertion of deltoid...................... 5121
Below insertion of deltoid...................... 5122
Digits, five of one hand............................ 5126
Digits, four of one hand:
Thumb, index, long and ring..................... 5127
Thumb, index, long and little................... 5128
Thumb, index, ring and little................... 5129
Thumb, long, ring and little.................... 5130
Index, long, ring and little.................... 5131
Digits, three of one hand:
Thumb, index and long........................... 5132
Thumb, index and ring........................... 5133
Thumb, index and little......................... 5134
Thumb, long and ring............................ 5135
Thumb, long and little.......................... 5136
Thumb, ring and little.......................... 5137
[[Page 35732]]
Index, long and ring............................ 5138
Index, long and little.......................... 5139
Index, ring and little.......................... 5140
Long, ring and little........................... 5141
Digits, two of one hand:
Thumb and index................................. 5142
Thumb and long.................................. 5143
Thumb and ring.................................. 5144
Thumb and little................................ 5145
Index and long.................................. 5146
Index and ring.................................. 5147
Index and little................................ 5148
Long and ring................................... 5149
Long and little................................. 5150
Ring and little................................. 5151
Single finger:
Thumb........................................... 5152
Index finger.................................... 5153
Long finger..................................... 5154
Ring finger..................................... 5155
Little finger................................... 5156
Forearm:
Above insertion of pronator teres............... 5123
Below insertion of pronator teres............... 5124
Leg:
With defective stump............................ 5163
Not improvable by prosthesis controlled by 5164
natural knee action............................
At lower level, permitting prosthesis........... 5165
Forefoot, proximal to metatarsal bones.......... 5166
Toes, all, amputation of, without metatarsal 5170
loss or transmetatarsal, amputation of, with up
to half of metatarsal loss.....................
Toe, great...................................... 5171
Toe, other than great, with removal metatarsal 5172
head...........................................
Toes, three or more, without metatarsal 5173
involvement....................................
Thigh:
Complete amputation, lower extremity............ 5160
Upper third..................................... 5161
Middle or lower thirds.......................... 5162
* * * * * * *
Arthritis:
Degenerative, other than post-traumatic......... 5003
Gonorrheal...................................... 5004
Other specified forms (excluding gout).......... 5009
Pneumococcic.................................... 5005
Post-traumatic.................................. 5010
Multi-joint (except post-traumatic and gout).... 5002
Streptococcic................................... 5008
Syphilitic...................................... 5007
Typhoid......................................... 5006
Arthropathy............................................. 5009
* * * * * * *
Bones:
Neoplasm, benign.................................... 5015
Neoplasm, malignant, primary or secondary........... 5012
Shortening of the lower extremity................... 5275
* * * * * * *
Colitis, ulcerative..................................... 7323
Compartment syndrome.................................... 5331
* * * * * * *
Dacryocystitis.......................................... 6031
Decompression illness................................... 5011
* * * * * * *
Hernia:
Femoral............................................. 7340
Hiatal.............................................. 7346
Inguinal............................................ 7338
Muscle.............................................. 5326
Ventral............................................. 7339
Heterotopic ossification................................ 5023
[[Page 35733]]
Hip:
Flail joint......................................... 5254
* * * * * * *
Hodgkin's disease....................................... 7709
Hydronephrosis.......................................... 7509
* * * * * * *
Myocardial infarction................................... 7006
Myositis................................................ 5021
* * * * * * *
Osteomalacia, residuals of.............................. 5014
* * * * * * *
Osteoporosis, residuals of.............................. 5013
* * * * * * *
Paralysis:
Accommodation....................................... 6030
Agitans............................................. 8004
Complete, traumatic................................. 5244
* * * * * * *
Pericarditis............................................ 7002
Peripheral vestibular disorders......................... 6204
* * * * * * *
Plague.................................................. 6307
Plantar fasciitis....................................... 5285
* * * * * * *
Prosthetic implants:
Ankle replacement................................... 5056
Elbow replacement................................... 5052
Hip, resurfacing or replacement..................... 5054
Knee, resurfacing or replacement.................... 5055
* * * * * * *
Retinitis............................................... 6006
Rhabdomyolysis, residuals of............................ 5330
* * * * * * *
Spinal stenosis......................................... 5238
Spine:
Degenerative arthritis, degenerative disc disease 5242
other than intervertebral disc syndrome............
* * * * * * *
Syndromes:
Chronic Fatigue Syndrome (CFS)...................... 6354
Cushing's........................................... 7907
Meniere's........................................... 6205
Raynaud's........................................... 7117
Sleep Apnea......................................... 6847
Syphilis................................................ 6310
* * * * * * *
Tenosynovitis, tendinitis, tendinosis or tendinopathy... 5024
* * * * * * *
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[FR Doc. 2017-15766 Filed 7-31-17; 8:45 am]
BILLING CODE 8320-01-P