Schedule for Rating Disabilities: The Digestive System
| Published date | 20 March 2024 |
| Record Number | 2024-05138 |
| Citation | 89 FR 19735 |
| Court | Veterans Affairs Department |
| Section | Rules and Regulations |
Federal Register, Volume 89 Issue 55 (Wednesday, March 20, 2024)
[Federal Register Volume 89, Number 55 (Wednesday, March 20, 2024)]
[Rules and Regulations]
[Pages 19735-19754]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-05138]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AQ90
Schedule for Rating Disabilities: The Digestive System
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
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SUMMARY: This document amends the Department of Veterans Affairs (VA)
Schedule for Rating Disabilities (VASRD) by revising the portion of the
schedule that addresses the Digestive System. The effect of this action
is to ensure that the rating schedule uses current medical terminology
and provides detailed and updated criteria for evaluation of digestive
conditions for disability rating purposes.
DATES: This final rule is effective May 19, 2024.
FOR FURTHER INFORMATION CONTACT: Ulia Sokol, M.D., M.B.A., Medical
Officer, Regulations Staff, (218A), Compensation Service, Veterans
Benefits Administration, Department of Veterans Affairs, 810 Vermont
Avenue NW, Washington, DC 20420, [email protected], (202) 461-
9700. (This is not a toll-free telephone number.)
SUPPLEMENTARY INFORMATION: On January 11, 2022, VA published in the
Federal Register the proposed rule for Schedule of Rating Disabilities:
The Digestive System. See 87 FR 1522. VA received 22 comments during
the 60-day comment period, including from two Veterans Service
Organizations (Paralyzed Veterans of America and The National Veterans
Legal Services Program) and two Veterans advocacy groups (The National
Organization of Veterans' Advocates, Inc. and The National Law School
Veterans Clinic Consortium). VA appreciates the comments submitted in
response to the proposed rule. Based on the rationale stated in the
proposed rule and in this document, the proposed rule is adopted as a
final rule with minor changes noted below.
Severability: The provisions of the proposed rule are separate and
severable from one another, and if any provision is stayed or
determined to be invalid, the agency would intend that the remaining
provisions continue in effect. VA has carefully considered the
requirements of the proposed rule, both individually and in their
totality, including their potential costs to the agency and benefit to
veterans. In the event a court were to stay or invalidate one or more
provisions of this rule as finalized, VA would want the remaining
portions of the rule as finalized to remain in full force and legal
effect.
I. Comments of General Support
One commenter expressed support for utilizing ``undernutrition''
instead of ``malnutrition'' under 38 CFR 4.112. VA thanks this
commenter for their input.
Another commenter expressed support for the proposed rule because
it provides more comprehensive evaluative criteria for those with
assisted nutrition devices such as gastrostomy tubes, total parenteral
nutrition (TPN) ports, and gastric stimulators. VA thanks this
commenter for their support.
One commenter expressed support for the change to DC 7326 for
Crohn's disease because it comprehensively addresses the symptoms of
this disease, its treatment modalities, and functional impairment
caused by this disease. VA thanks this commenter for their support.
While most commenters generally welcomed modernizing the rating
schedule and recognized this effort as a thoroughly-researched
undertaking, some commenters shared some concerns with VA. These
concerns are addressed in the sections below.
II. Comments Regarding Coexisting Abdominal Conditions Under Sec.
4.114, Schedule of Ratings--Digestive System
Two commenters expressed concern regarding the prohibition of
rating coexisting abdominal conditions under 38 CFR 4.113 and 4.114,
stating they are too broad in scope. One commenter recommended VA
should simply have rating specialists consider the anti-pyramiding
principles set out in 38 CFR 4.14. The other commenter suggested that
VA specifically reconsider adding the following diagnostic codes to the
list of codes that cannot be combined with each other: DC 7303, chronic
complications of upper gastrointestinal surgery, DC 7350, liver
abscess, DC 7352, pancreas transplant, DC 7355, celiac disease, DC
7356, gastrointestinal dysmotility syndrome, and DC 7357, post
pancreatectomy. It was the commenter's opinion that this approach is
restrictive and precludes the ability to maximize benefits for
veterans.
[[Page 19736]]
VA makes no changes based on these comments. First, the addition of
the newly created diagnostic codes is appropriate due to 38 CFR 4.14
and 4.113, which advises rating personnel to avoid providing multiple
evaluations for the same disability under various diagnoses. Even
though VA is adding diagnostic codes for new conditions, the symptoms
and functional impairment experienced by these new conditions are
commonly shared with other diagnoses found in this body system and
therefore cannot be combined. Next, while 38 CFR 4.114 adheres to the
provisions laid out in 38 CFR 4.14, it provides a benefit that 38 CFR
4.14 does not--it allows rating personnel to elevate the evaluation to
the next higher level when warranted based on the overall disability
severity. This is a benefit to the veteran that is not available
through the application of 38 CFR 4.14 alone and provides a favorable
means of accounting for non-overlapping symptoms. For example, consider
a veteran evaluated at 30% for the predominant disability of Crohn's
disease (DC 7326) and 30% for diverticulitis (DC 7327) with non-
overlapping symptoms. When applying the symptoms of diverticulitis to
Crohn's, the resultant evaluation is higher than that of Crohn's alone
warranting an elevation to the next higher level under DC 7326, which
is 60%. The regulation in 38 CFR 4.14 does not allow for elevations in
this way. Therefore, it is more advantageous that the provisions of 38
CFR 4.114 be applied for these diagnostic codes than 38 CFR 4.14.
However, VA notes that the terminology used in this paragraph can be
revised to aid its interpretation and application. The paragraph
advises rating personnel to not combine diagnostic codes and to assign
a single evaluation that reflects the predominant disability picture.
The term ``combine'' in this paragraph refers to combining disabilities
as defined in 38 CFR 4.25 for the purposes of determining the combined
disability evaluation, but it can be misinterpreted as stating to not
provide service connection for multiple conditions under these
diagnostic codes. To simplify this language and ensure clarity, VA
revises it to state that ratings under these diagnostic codes will be
assigned a single evaluation that reflects the predominant disability
picture and that elevation to the next higher evaluation can be
provided if warranted based on the severity of the overall disability.
III. Comments Regarding DC 7202 Tongue, Loss of Whole or Part
One commenter recommended that VA remove the note under DC 7202 to
review for Special Monthly Compensation (SMC) for tongue, loss of whole
or part because the evaluative criteria no longer evaluates aphonia.
Another commenter asked VA to, ``restore criteria under DC 7202 for the
amount of tongue removed and speech impairment to address . . .
situations where communication is impaired but not precluded'' as
necessary for the grant of special monthly compensation for complete
organic aphonia. Otherwise, the commenter recommended VA refer to
another body system that adequately addresses speech impairment due to
loss of tongue.
First, the VASRD has two diagnostic codes that provide evaluations
for speech impairment. One of those diagnostic codes, DC 6519 for
organic aphonia, is the most appropriate catch-all for speech
impairment issues due to infection, disease, or in the case of loss of
whole or part of the tongue, injury. Additionally, DC 6519 provides
objective criteria to adequately evaluate situations where speech is
impaired but not precluded. Second, the intent of Note 1 is to provide
general guidance to the rating personnel to capture any additional
functional impairment that comes with the loss of the tongue, whole or
partial. However, VA agrees that removing the note about SMC is
warranted and that the note should more directly guide rating personnel
to the more appropriate diagnostic code to evaluate speech impairment
that can arise due to whole or partial loss of the tongue. Therefore,
VA revises Note 1 of DC 7202 to refer rating personnel to DC 6519 or DC
6516 when there is evidence of speech impairment. VA thanks these
commenters for their input.
The same commenter pointed out that in the preamble of the proposed
rule for DC 7202, VA failed to demonstrate how medical treatment and
rehabilitation can restore speech function to varying degrees. VA
acknowledges that speech rehabilitation methodology and references to
other body systems were not discussed in the preamble because those are
outside the scope of this rulemaking. From a disability compensation
standpoint, VA already has regulations to address evaluations that need
review if speech function is restored or the condition otherwise
improves. See 38 CFR 3.344 and 3.327. VA thanks this commenter but
makes no changes based on this comment.
One commenter suggested that VA should recognize that both the
abilities to swallow and to speak are highly relevant and should be
considered under DC 7202. Additionally, the commenter recommended that
VA provide a 30% evaluation for marked loss of speech due to loss of
tongue. While VA agrees that the ability to swallow and to speak may be
impaired due to the loss of tongue in whole or in part, speech is not a
function of the digestive body system. Speech impairment has no effect
on whether one is able to sufficiently consume or digest sustenance.
Therefore, it is more appropriate for the evaluative criteria of this
condition to be limited to its effect on food consumption. Thus, VA
makes no changes based on this comment.
Finally, the same commenter suggested that VA specify that
``medical advisors'' under DC 7202 are not limited to physicians but
may also include physician assistants, nurse practitioners and
nutritionists. While VA agrees that physicians are not the only medical
providers who may provide care, the term ``medical provider'' is used
throughout the VASRD to encompass a variety of healthcare professionals
who provide health care services, to include medical care or treatment.
This is consistent with the use of the term ``medical providers''
outside of VA as well. Therefore, VA makes no changes based on this
comment.
IV. Comments Regarding DC 7203 Esophagus, Stricture of
One commenter noted that VA use ``dilation'' and ``dilatation'' in
the evaluation criteria and asked if the terms should be used
interchangeably. VA recognized that there was a typographical error and
all instances of the word should have been ``dilatation.'' VA makes a
clarifying change that amends the proposed text by replacing the word
``dilation'' with ``dilatation'' at the 50% level, and in Note 5 of DC
7203.
The same commenter asked VA to clarify if surgical correction only
refers to procedures to correct esophageal strictures or if it also
includes surgeries that relieve gastroesophageal reflux disease (GERD)
such as Nissen fundoplication. VA clarifies that surgical correction
only warrants the 80% evaluation when it is used to treat esophageal
stricture(s). We make no change to DC 7203 based on this comment, but
make a clarifying change to similar language in DC 7206 as discussed
under Section XVIII, Technical Corrections, in this document.
Another commenter noted that the definition of refractory requires
at least five dilatation treatments at two-week
[[Page 19737]]
intervals and that the 50% criteria is warranted when dilatation occurs
three or more times per year; however, refractory esophageal strictures
can receive 30% evaluations, which are warranted when dilatation occurs
no more than two times per year. The commenter questioned how
refractory esophageal stricture could warrant a 30% evaluation if, by
definition, it requires five dilatations per year. VA agrees and
revises the 30% criteria to only include recurrent esophageal
strictures while the 50% criteria will reference both recurrent and
refractory esophageal strictures. VA appreciates the input of these
commenters.
V. Comments Regarding DC 7206 Gastroesophageal Reflux Disease
One commenter questioned why there was no mention of the GERD
evaluative criteria in the Economic Regulatory Impact Analysis (ERIA).
The discussion regarding how GERD is evaluated was described in the
preamble of the proposed rule. The ERIA is a systemic approach to
assessing the positive and negative budgetary effects of proposed and
existing regulation and non-regulatory alternatives. Budgetary
documentation does not require information regarding how a condition is
evaluated because that is not considered pertinent to cost analysis. In
the ERIA, VA compares the current evaluation levels for DC 7346 with
the proposed evaluation levels for new DC 7206. For budgetary
discussions, this is an appropriate methodology to estimate impact of
proposed changes.
The same commenter questioned why VA categorized GERD as having a
``minor budgetary impact'' in the ERIA. As stated in the ERIA, the term
``minor budgetary impact'' is defined as having costs less than $100
million over ten years. GERD as a standalone item is anticipated to
have a minor budgetary impact under that definition, whereas the
digestive rule overall is anticipated to have a major budgetary impact
(i.e., greater than $100 million over 10 years).
Four commenters recommended that VA discontinue rating GERD by
analogy or reference. In its proposed rule, VA introduced a new
diagnostic code, DC 7206, with instructions to rate this condition
under DC 7203. VA agrees that DC 7206 warrants its own rating criteria
to provide clarity in its application. However, as indicated in the
proposed rule, VA proposes to evaluate GERD using rating criteria that
are based on predominant picture of disability due to GERD. These
criteria consider symptoms of esophageal obstruction and irritation
that lead to the esophageal stricture, which are consistent with the
symptoms of GERD and clearly identified under DC 7203, Esophagus,
stricture of. D. Armstrong et al., ``Canadian consensus conference on
the management of gastroesophageal reflux disease in adults: Update
2004,'' 19(1) Canadian J. of Gastroenterology, 15-35 (Jan. 2005).
Therefore, VA amends the proposed rule by placing the text of the
evaluation criteria for DC 7206 following its title. DC 7206 will not
be rated by reference to DC 7203. VA thanks the commenters for their
suggestions and has updated this DC to reflect this change.
Six commenters expressed concern that the evaluative criteria for
DC 7206 do not include symptoms of heartburn, regurgitation, sore
throat, nausea, chest pain, difficulty swallowing, laryngitis, chronic
cough, new or worsening asthma, inflammation of the gums, cavities, bad
breath, disrupted sleep, ulceration, erosion or Barrett's esophagus.
Three of those six commenters proposed that VA continue to evaluate
GERD under the current rating schedule, analogous to DC 7346 for hiatal
hernia.
Even though these symptoms are important in the diagnosis and
treatment of GERD, the VA rating schedule bases its evaluations on the
permanent impairment due to this condition. Such permanent impairment
of function is based on the scarring due to the chronic irritation of
the esophagus by acid reflux and consequent development of scar tissue
that causes esophageal stricture. See Desai JP, Moustarah F.,
Esophageal Stricture [Updated 2021 May 27], https://www.ncbi.nlm.nih.gov/books/NBK542209/. Therefore, for VA disability
compensation purposes, the functional impairment due to GERD will be
evaluated and based on the degree of esophageal stricture. VA makes no
changes based on these comments.
Two commenters expressed concern that VA has not considered the
functional impairment posed by GERD. VA disagrees. The VASRD provides
evaluative criteria in line with 38 U.S.C. 1155 (the statute that
governs implementation of the ratings schedule) for the evaluation
based on the average impairments of earning capacity resulting from
comparable injuries in civilian occupations. Accordingly, VA has
incorporated considerations regarding the functional impairment caused
by each disability evaluation in its rating criteria. Therefore, VA
makes no changes based on these comments.
Three commenters expressed concern that while esophageal stricture
is commonly caused by GERD, not all GERD cases result in esophageal
stricture. While this is true, esophageal stricture is more often than
not the result of under-treated, late-stage, or refractory GERD. As
stated above, the purpose of the VASRD is to evaluate the permanent
residuals of a disability pursuant to 38 U.S.C. 1155. VA makes no
changes based on these comments.
Two commenters expressed concern that by changing the VASRD for
digestive disabilities, including GERD, VA is attempting to save money
and create a higher burden to obtain compensable evaluations. VA
disagrees. As stated in the preamble of the proposed rule, the purpose
of this rule was to reflect medical and scientific advances in the
understanding and treatment of digestive disorders. 87 FR 1522 (Jan.
11, 2022). For example, GERD is more appropriately evaluated as
esophageal stricture than hiatal hernia based on objective findings.
Id. at 1525 (citing D. Armstrong et al., ``Canadian consensus
conference on the management of gastroesophageal reflux disease in
adults: Update 2004,'' 19(1) Canadian J. of Gastroenterology, 15-35
(Jan. 2005)). This adjustment from evaluating GERD based on subjective
symptoms to objective measurements is consistent with the stated
purpose of this rule. Therefore, VA makes no changes based on these
comments.
One commenter was concerned because the 2004 study cited in the
proposed rule stated its objective was to ``develop up-to-date
evidence-based recommendations relevant to the needs of Canadian health
care providers for the management of the esophageal manifestations of
GERD,'' and the study's author noted that ``GERD significantly impairs
quality of life, both in patients with erosive esophagitis and in those
who have no endoscopic evidence of injury[.]''
As stated above, functional impairment is the basis for formulating
VASRD evaluative criteria. However, ``quality of life'' is not a
quantifiable measurement for VA disability purposes as VA measures
functional impairment pursuant to 38 U.S.C. 1155. It is the intent of
this rule to incorporate modernized terminology and accepted clinical
treatment into the VASRD. VA recognizes the importance of the symptoms
that were mentioned by the commenter (e.g., erosions, ulcerations and
Barrett's esophagus) in the diagnosis and treatment of GERD; however,
the VASRD concentrates on the ongoing impairment due to this condition.
Ongoing impairment of function due to GERD is based on the scarring due
to the chronic irritation of the esophagus by acid reflux and
consequent development of scar tissue
[[Page 19738]]
that causes esophageal stricture. Therefore, for VA disability
compensation purposes, the functional impairment due to GERD will be
evaluated and based on the degree of esophageal stricture. Thus, VA
makes no changes based on this comment.
One commenter suggested that acid reflux more than three times a
week should warrant a 20% evaluation. VA disagrees. Acid reflux is
already considered in the 10% evaluation, but VA sought a more
objective measure--specifically, the prescription of medication on a
daily basis--rather than assessing frequency of acid reflux events. And
VA compensates such medication usage at the 10% level consistent with
other conditions that require daily medication for control (e.g.,
cardiac conditions rated under 38 CFR 4.104). VA thanks the commenter
for their suggestion but makes no changes to the rule.
VI. Comments Regarding DC 7319 Irritable Bowel Syndrome (IBS)
One commenter asked whether an individual could submit a claim for
DC 7207 Barrett's esophagus and DC 7319 irritable bowel syndrome (IBS)
or DC 7326 Crohn's disease. Neither 38 CFR 4.113 nor 38 CFR 4.114
prohibit separate evaluations of any 7200 series conditions and 7300
series conditions. Thus, Barrett's esophagus and either IBS or Crohn's
disease may be separately evaluated without pyramiding if there are no
similar comorbid symptoms. The same commenter asked a question
regarding submitting a personal benefit application for these
conditions. VA always encourages veterans to file claims for benefits
to which they believe they are entitled and to seek assistance with
filing claims from accredited representatives whenever necessary.
However, VA does not respond to comments regarding individual claims in
rulemakings. VA thanks the commenter and makes no changes based on this
comment.
One commenter expressed concern that the terms ``change in stool
frequency'' and ``change in stool form'' used under DC 7319 are
ambiguous and highly subjective and could cause confusion and
disagreements as to the timeframe such change occurred. The commenter
further stated that while it generally supports VA implementing more
objective rating criteria based on the Rome IV criteria, the proposed
changes ``should not mirror this undefined language in the Rome IV
criteria.'' Instead, the commenter suggested explicitly stating in the
evaluative criteria that these changes occurred after the onset of IBS.
VA reserves some of the more detailed instructions, such as the
definition of ``change'' as it relates to stools for IBS, for its
subregulatory guidance. Generally, the VASRD does not provide
definitions of common clinical guidelines. Rather, VA relies on the
medical community to adhere to current medical practice and standards,
or otherwise provides the definition of medical terms in subregulatory
guidance. In this instance, VA will accept the recorded findings of a
qualified medical provider using the Bristol Stool Scale, also known as
Meyers Scale, to indicate whether stool frequency and form has changed.
VA will identify these findings in the training for use of the
appropriate disability benefits questionnaires (DBQs). Therefore, VA
makes no changes based on this comment.
One commenter stated that limiting the evaluation of IBS under DC
7319 to a maximum schedular evaluation of 30% does not contemplate the
functional impairment posed by those experiencing severe and frequent
symptoms. The commenter suggested that DC 7319 instead provide a 50%
evaluation, comparable to migraine headaches under DC 8100, to account
for severe economic inadaptability. For evaluative purposes, severe
economic inadaptability denotes a degree of substantial work impairment
but does not preclude substantially gainful employment.
Since the 1960s, VA has moved away from including work-specific
criterion and instead focused solely on the functional impact caused by
the condition in its evaluative criteria. The establishment of a
maximum 30% schedular evaluation reflects VA's judgement as to the
average occupational impairment resulting from IBS. In exceptional
cases where IBS has an unusually severe impact on earning capacity, VA
may consider extraschedular ratings under 38 CFR 3.321 and 4.16.
Additionally, in its proposed rule, VA did not propose to change
the number of disability levels for the assessment of functional
impairment due to IBS. VA kept the same 30%, 10%, and 0% evaluation
levels, but updated them with more objective criteria derived from the
Rome IV criteria for IBS. See 87 FR 1522, 1530 (Jan. 11, 2022) (citing
Brian Lacy, ``Bowel Disorders,'' Gastroenterology, 150: 1393-1407
(2016)). VA thanks the commenter for the suggestion but makes no change
based on this comment.
Finally, the same commenter suggested that VA include a reference
to DC 7332 for impairment of sphincter control of the rectum and anus
for veterans who experience incontinence due to IBS. VA does not
routinely create notes for all possible comorbid manifestations of a
disease process and declines to do so in this circumstance. The
regulation in 38 CFR 4.2 advises rating specialists to interpret
medical evidence so that the appropriate disability is evaluated. VA
thanks the commenter for this suggestion, but makes no changes based on
this comment.
VII. Comments Regarding DC 7326 Crohn's Disease or Undifferentiated
Form of Inflammatory Bowel Disease
One commenter expressed support for the change to DC 7326 for
Crohn's disease because it comprehensively addresses the symptoms of
this disease, all treatment modalities and functional impairment caused
by this disease. VA thanks this commenter for their support.
One commenter shared their personal experience with Crohn's disease
treatment and management. Additionally, the commenter expressed concern
about medical coverage for veterans and the burden of co-payments for
medical treatment. VA appreciates this comment, but medical care
benefit issues are outside of the scope of this rulemaking. Therefore,
VA makes no changes based on this comment.
The same commenter noted that mental disorders are frequently
diagnosed subsequent to Crohn's disease and should be addressed
accordingly. Currently, VA has the authority to grant entitlement to
service connection on a secondary basis for disabilities that are
proximately due to, or aggravated by, service-connected disease or
injury pursuant to 38 CFR 3.310. This would allow VA to service connect
a mental disorder due to Crohn's disease without any additional
revisions to the portion of the rating schedule which addressed
digestive disabilities. Therefore, VA makes no changes based on this
comment.
The same commenter suggested using a 100-point system developed by
Crohn's and Colitis Foundation of America. However, this point system
was developed for diagnosis, treatment and management of these diseases
in a clinical setting and is not appropriate to be used for disability
evaluation. Therefore, VA makes no changes based on this comment.
Finally, the same commenter expressed support for the rule change
for DC 7326 Crohn's disease because it more accurately defines the
functional impairment in its rating criteria. VA thanks the commenter
for their support.
[[Page 19739]]
VIII. Comments Regarding DC 7329, Intestine, Large, Resection of
One commenter suggested that the 100% evaluation criteria for DC
7329 Intestine, large, resection of, should simply consist of the
elements from the 60% criteria with one additional element (high-output
syndrome) instead of three additional elements. The commenter's concern
was that veterans could experience inconsistent ratings if they fall
between these two requirements, such as a total colectomy with high-
output syndrome but no ileostomy. Additionally, the commenter suggested
adding an intermediary 80% evaluation under this DC to cover the cases
that fall between these two requirements.
The proposed 100% evaluation criteria include three major elements,
(1) total colectomy with (2) formation of ileostomy and (3) high-output
syndrome with more than two episodes of dehydration in the past 12
months. The episodes of dehydration that require intravenous hydration
are reflective of the gravity of the consequences of the large
intestine resection, demonstrating total impairment. The functional
impairment due to total colectomy with high-output syndrome and total
colectomy without high-output syndrome has clear demarcation along the
absence or presence of said high-output syndrome. Therefore, VA
proposed clearly identifiable levels of disability for the 60% and 100%
evaluation based on that principle. Furthermore, 38 CFR 4.7 already
provides guidance to rating specialists to assign the next higher
evaluation should the disability picture more closely approximate that
level of disability. VA thanks the commenter for their suggestions but
declines to make changes based on this comment.
However, during its internal review, VA noted a minor inconsistency
in using certain terminology for surgical outcomes for a 40% evaluation
for a partial colectomy with permanent colostomy and for a 60%
evaluation for total colectomy without high-output syndrome. VA
corrects this inconsistent use of medical terminology by revising the
40% evaluative criteria to read as ``Partial colectomy with permanent
colostomy or ileostomy without high-output syndrome'' and 60%
evaluative criteria to read as ``Total colectomy with or without
permanent colostomy or ileostomy without high-output syndrome.'' This
clerical change brings additional clarity to the rating criteria for
the 20%, 40%, 60% and 100% ratings, and assures their consistent
application by rating specialists. This revision does not result in any
substantive changes to the criteria under DC 7329.
IX. Comments Regarding DC 7332, Rectum and Anus, Impairment of
Sphincter Control
One commenter requested clarification between the terminology
``wearing'' and ``changing'' of pads under DC 7332, rectum and anus,
impairment of sphincter control. VA's proposed rating criteria provided
descriptive criteria that track the Cleveland Clinic Incontinence Scale
(CCIS), a standardized, evidence-based measure that accounts for
difficulties with retention and expulsion of stool. This scale
determines the severity of sphincter impairment, the frequency of
incontinence, and the extent to which it alters a person's life. See
A.M. Kaiser, ``The McGraw-Hill Manual of Colorectal Surgery,'' 743
(2009). For the purposes of VA disability compensation, the term
``changing'' of pads refers to the need to change a pad due to an
incontinence to gas, incontinence to liquid or incontinence to solid
and the resulting soiling of the pad. The term ``wearing'' of pads
refers to a necessary or advisable measure to address the effects of
incontinence, regardless of the frequency with which soiling occurs.
One commenter expressed concern regarding the proposed changes to
DC 7332 because the evaluative criteria list specific findings that may
be applied more rigidly than the existing criteria. The same commenter
proposed VA instead create a non-exclusive example to demonstrate
levels of loss of control without applying specific findings. As
compared to the existing rating criteria, the proposed rule contains
successive criteria, which offer clear and objective findings at each
level of impairment in line with the CCIS. Additionally, the proposed
criteria replace subjective terminology such as ``extensive,''
``frequent,'' ``occasional,'' and ``slight'' with measurable
descriptive findings that clarify existing rating criteria.
Furthermore, each level of disability allows for evaluation based on
responsiveness to treatment or frequency of incontinence with use of
pads, which allows flexibility in applying disability evaluation. VA
thanks the commenter for their suggestion but makes no changes to the
rule based on this comment.
The same commenter was concerned that the proposed criteria under
DC 7332 may impose a higher burden than current procedures to award
entitlement to special monthly compensation (SMC) under 38 CFR
3.350(e)(2) and 38 U.S.C. 1114(o) for paraplegia. VA disagrees. Aside
from making the criteria more objective, VA's proposed revision to this
diagnostic code includes consideration as to whether loss of anal
sphincter control is responsive to treatment. This is not incompatible
with SMC for paraplegia. Rather, 38 CFR 3.350(e)(2) states that ``[t]he
requirement of loss of anal and bladder sphincter control is met even
though incontinence has been overcome under a strict regimen of
rehabilitation of bowel and bladder training and other auxiliary
measures.'' The fact that the evaluative criteria have become more
objective and include consideration of treatment response does not make
it more difficult to be awarded SMC due to paraplegia than under
current requirements. Therefore, VA makes no changes to this rule based
on this comment.
X. Comments Regarding DC 7336, Hemorrhoids, External or Internal
One commenter expressed concern that the 0% (noncompensable)
evaluation for hemorrhoids under DC 7336 was removed without
explanation and requested VA reinstate this evaluation. Current VASRD
criteria warrant a 0% evaluation for mild or moderate internal or
external hemorrhoids. These rating criteria are unquantifiable and
nonspecific; therefore, VA removed them. However, 38 CFR 4.31 requires
VA raters to assign a noncompensable evaluation for any diagnostic code
in the VASRD where one is not present when the requirements for a
compensable evaluation are not met. Therefore, VA can still assign 0%
evaluations for hemorrhoids despite the evaluation level being removed.
Additionally, the commenter was concerned that without a
noncompensable evaluation under DC 7336 for hemorrhoids, veterans would
not be eligible for the 10% evaluation awarded for two or more
noncompensable evaluations under 38 CFR 3.324. As stated above, despite
the removal of the noncompensable evaluation under DC 7336, veterans
may be eligible for a 10% rating based on two or more noncompensable
evaluations under 38 CFR 3.324 even if those noncompensable evaluations
are awards through 38 CFR 4.31. Therefore, VA makes no changes based on
this comment.
XI. Comments Regarding DC 7345, Chronic Liver Disease Without Cirrhosis
One commenter suggested adding a 10% evaluation under DC 7345 for
chronic liver disease without cirrhosis to account for those in
remission who
[[Page 19740]]
may experience spontaneous reactivation of hepatitis B and/or
experience mental health symptoms related to the anxiety that
spontaneous reactivation could occur. Proposed DC 7345 provides a 0%
evaluation for those with a history of liver disease who are
asymptomatic. Compensable evaluations, 10% or more, are based on
laboratory findings and/or symptoms associated with a disease. Should
the disease recur, the veteran may submit a claim for increase based on
recurrence and level of severity. Regarding mental symptoms associated
with chronic liver disease, VA may grant entitlement to service
connection on a secondary basis for disabilities that are proximately
due to, or aggravated by, service-connected disease or injury pursuant
to 38 CFR 3.310. VA thanks this commenter, but makes no changes based
on this comment.
XII. Comments Regarding DC 7347, Pancreatitis, Chronic
One commenter was concerned that the enteral feeding element of the
rating criteria is not included in every evaluation level under DC
7347, Pancreatitis, chronic. Additionally, the commenter asked for
further clarification on how to rate this condition if it requires
enteral feeding, regardless of whether or not the feeding causes
complication. The commenter also stated that other proposed criteria,
specifically DCs 7301, 7303, and 7328, provide an 80% disability rating
for enteral feeding whereas this code and 7330 only provide 60%. The
commenter suggested that VA consider applying the 80% rating for
enteral feeding to align it with the rest of the proposed ratings.
First, VA closely examined the full range of functional impairment
due to the chronic pancreatitis during its review of this VASRD body
system. VA found that the proposed rating criteria is aligned
appropriately with the functional impairment due to the chronic
pancreatitis, as described in the preamble of the proposed rule. To
that end, consideration of enteral feeding is not necessary at every
evaluation level.
Second, DCs 7301, 7303, and 7328 provide an 80% disability rating
for TPN, not enteral feeding. TPN provides nutrition outside of the
digestive tract (intravenously), whereas enteral feeding provides
nutrition through the digestive tract by way of a feeding tube.
Additionally, TPN is primarily indicated when enteral feeding is not
possible. See Maudar K.K. (1995), TOTAL PARENTERAL NUTRITION, Medical
journal, Armed Forces India, 51(2), 122-126, https://doi.org/10.1016/S0377-1237(17)30942-5. Thus, TPN is assigned a higher evaluation than
enteral feeding based on the need for intravenous nutrition due to the
greater impairment of functioning of the digestive tract. Therefore, VA
makes no changes based on this comment.
XIII. Comments Regarding DC 7355, Celiac Disease
One commenter suggested using ``undernutrition'' instead of
``malabsorption syndrome'' under DC 7355 for celiac disease because
malabsorption is not defined in the VASRD, and it ultimately results in
undernutrition. VA disagrees. Malabsorption syndrome is separate from
undernutrition condition; these two conditions cannot be used
interchangeably. Furthermore, malabsorption syndrome has its own clear
clinical definition and does not have to be defined in the VASRD.
Therefore, VA makes no changes based on this comment.
XIV. Comments Regarding Dysphagia
One commenter asked whether the term dysphagia is defined in this
rule as difficulty swallowing or a condition encompassing a variety of
symptoms such as pain while swallowing, a sensation of food getting
stuck in the throat or chest, drooling, hoarseness, regurgitation, etc.
As stated above, the VASRD does not provide detailed definitions of
common clinical guidelines. Qualified clinicians may determine the
presence or absence of any symptoms of GERD upon examination, including
the common symptom of dysphasia, which may manifest as a variety of
symptoms including difficulty of swallowing. VA thanks the commenter
but makes no changes to the rule based on this comment.
XV. Comments Regarding General Terminology
One commenter expressed concern regarding with the inconsistency of
using general terminology, such as ``prescribed dietary modification,''
``dietary intervention,'' and ``dietary restriction'' under a number of
diagnostic codes. VA uses all three references--prescribed dietary
modification, dietary intervention, and dietary restriction--to
describe different types of therapeutic diets. A therapeutic diet is a
meal plan that controls the intake of certain foods or nutrients and is
part of the treatment of a medical condition and is normally prescribed
by a physician and planned by a dietician. A therapeutic diet is
usually a modification of a regular diet, and it is modified or
tailored to fit the nutrition needs of a particular person. VA uses
these references as appropriate under specific diagnostic codes
according to specific clinical situations. Additionally, in issuing its
proposed rule, VA provided specific examples of prescribed dietary
modification (e.g., therapeutic diets can be modified for nutrients or
texture due to impaired swallowing or frequent aspiration), dietary
intervention (e.g., a prescribed gluten-free diet), and dietary
restriction (e.g., a reduction of particular or total nutrient intake
without causing malnutrition). Therefore, VA makes no changes based on
this comment.
The same commenter stated that the 30% criteria for DC 7356,
Gastrointestinal dysmotility syndrome, is repetitive and misleading
because it requires both symptoms of intestinal pseudo-obstruction
(CIPO) and symptoms of intestinal motility disorder, but CIPO is an
intestinal motility disorder. VA agrees and revises the criteria at the
30% level to use ``or'' instead of ``; and.'' CIPO is a specific
diagnosis of an intestinal motility disorder, so use of the conjunctive
``and'' makes reference to CIPO redundant. VA thanks the commenter for
their comment.
Additionally, the commenter questioned whether recurrent emergency
treatment for the 50% evaluation for DC 7356 only applies to episodes
of intestinal obstruction or if it also applies to regurgitation. VA
clarifies once more that the recurrent emergency treatment for the 50%
evaluation also applies to regurgitation due to poor gastric emptying,
abdominal pain, recurrent nausea or recurrent vomiting. The commenter
asked that VA adjust the wording for further clarification. However, VA
notes that when evaluation criteria use the disjunctive ``or'' without
a semi-colon, then ``or'' indicates that the qualifier applies to
criterion on both sides of the ``or.'' That is the case regarding
recurrent emergency treatment in this evaluation. Conversely, when VA
uses ``or'' with a semi-colon, then the qualifier only applies to the
criterion on the same side of the semi-colon. Therefore, a 50%
evaluation would be warranted if the evidence demonstrated intermittent
tube feeding for nutritional support, along with recurrent emergency
treatment for either intestinal obstruction due to poor gastric
emptying, abdominal pain, recurrent nausea, or recurrent vomiting or
regurgitation due to poor gastric emptying, abdominal pain, recurrent
nausea, or recurrent vomiting. VA makes no changes based on these
comments.
[[Page 19741]]
XVI. Comments of General Disagreement
One commenter indicated that the current VASRD does not incorporate
the most up-to-date and accurate scientific data because its rating
criteria do not allow clinicians to more accurately diagnose and
therefore to fairly distribute disability services. The VASRD is not
intended to be utilized in a clinical setting to identify, diagnose or
treat injuries, diseases or disorders. The VASRD provides evaluative
criteria based on the average impairments of earning capacity resulting
from comparable injuries in civilian occupations, in line with VA's
authority under 38 U.S.C. 1155 to adopt a rating schedule. Clinicians
are urged to utilize standard diagnostic and treatment practices in
their respective clinical setting. Therefore, VA makes no changes based
on this comment.
Two commenters expressed concern that VA is taking benefits away
from veterans and disagreed with the rule change in general. The
commenters did not offer any specific recommendations. The primary
objective for this rule is to revise the rating criteria to reflect
updated medical advances, add new medical conditions and update
terminology. There are no provisions in this rule that seek to remove
any entitlement to benefits, and this rule would not disturb ratings
currently in effect. Therefore, VA makes no changes based on these
comments.
XVII. Comments Beyond the Scope of This Rulemaking
One commenter shared their experience seeking diagnoses for their
digestive symptoms due to Gulf War Illness. The regulation in 38 CFR
3.317(a)(2)(i)(B)(3) creates a presumption of service connection for
certain Persian Gulf veterans who exhibit functional gastrointestinal
disorders. The presumption of service connection for those disorders
falls outside the scope of this rulemaking. Commentary or advice for
questions regarding individual claims also fall outside of the scope of
this rulemaking. Therefore, VA makes no changes based on this comment.
XVIII. Technical Corrections
During its internal review, VA identified a number of minor issues
that are clerical and typographical in nature and took a corrective
action in its final rule with minor changes as noted below.
VA makes a minor typographical correction to revised Sec.
4.112(d)(2). In the proposed rule, the last sentence of the revised
regulation used the word ``parental'' when describing the function of
nasogastric or nasoenteral feeding tubes. VA amends this sentence by
replacing ``assisted parental nutrition'' with ``assisted parenteral
nutrition.'' This change to the language does not result in any
substantive changes to Sec. 4.112(d)(2).
VA makes minor clerical changes to the paragraph under 38 CFR
4.114, Schedule of ratings--digestive system. To streamline this
regulatory language and to ensure its clarity, VA revises 38 CFR 4.114
to (1) state that ratings under these diagnostic codes will be assigned
a single evaluation that reflects the predominant disability picture
and (2) that, if warranted, elevation of the disability rating to the
next higher evaluation level can be provided and will be based on the
severity of the overall disability under 38 CFR 4.114. This change to
the language does not result in any substantive changes to the
paragraph under 38 CFR 4.114, Schedule of ratings--digestive system.
VA makes a minor clerical correction to DC 7206, Gastroesophageal
reflux disease, to the 80% disability level language. To promote
clarity, VA amends the evaluative criteria for an 80% disability rating
by adding the words ``of esophageal stricture(s)'' after ``treatment
with either surgical correction.'' This clerical change is intended to
specify that the surgical correction applies only to correction of
esophageal stricture(s) and not any other conditions. This change does
not result in any substantive changes to the criteria under DC 7206.
VA makes clerical changes under DC 7303, Chronic complications of
upper gastrointestinal surgery. The 30% and 50% disability ratings
discussed ``vomiting not controlled by oral dietary modification'' or
``vomiting not controlled by medical treatment.'' To promote clarity,
VA removes the phrase ``not controlled by'' and replaces it with the
word ``despite.'' This change to the language does not result in any
substantive changes to the criteria under DC 7303.
VA makes two clerical changes under DC 7304, Peptic ulcer disease.
First, the rating criteria under the 0% disability rating mentions an
x-ray test as one of the diagnostic imaging studies to record a history
of peptic ulcer disease. VA replaces the reference to just one
diagnostic imaging study, such as an x-ray test, with a general
reference to diagnostic imaging studies, such as an X-ray, CT scan,
MRI, and others. This clerical change brings additional clarity to the
rating criteria for a 0% evaluation. This change to the language does
not result in any substantive changes to the criteria under DC 7304.
Second, VA amends the note under DC 7304 to include the following
standard instruction: ``Apply the provisions of Sec. 3.105(e) to any
change in evaluation based upon that or any subsequent examination.''
This clerical change is consistent with the reduction of evaluations
under 38 CFR 3.105(e) and with notes regarding mandatory VA medical
examinations throughout the VASRD. While VA inadvertently left this
instruction out of the proposed rule, this addition does not result in
any substantive changes to the criteria under DC 7304.
VA makes a clerical change under DC 7312, Cirrhosis of the liver.
In the proposed rule, one of the criteria for a 100% evaluation is
listed as encephalopathy, whereas one of the criteria for a 60%
evaluation is listed as hepatic encephalopathy. To avoid confusion and
ensure consistency in the application of the rating schedule, VA
replaces the phrase ``encephalopathy'' in the 100% criteria with
``hepatic encephalopathy.'' This change to the language does not result
in any substantive changes to the criteria under DC 7312.
VA makes a clerical change to the note under DC 7317, Gallbladder,
injury of. In the proposed rule, VA instructs adjudicators that
adhesions are not necessary when rating under DC 7301 (Adhesions of the
peritoneum due to surgery, trauma, disease, or infection). As written,
this note appears contradictory and could lead to confusion in applying
the correct evaluation. To clarify the intent of this note, VA makes a
minor clerical change by stating that when gallbladder injuries are
rated by analogy under DC 7301, a finding of adhesion is not necessary.
This change is structural in nature and does not result in any
substantive changes to the rating criteria.
VA identified that DC 7319 had one note labeled Note 1. There is
only one note in relation to DC 7319 and, therefore, no numerical
designation is required. To provide consistency and clarity, VA
corrects this typographical error and revises DC 7319 to remove the
numerical designation.
VA makes a clerical change under DC 7319, Irritable bowel syndrome
(IBS) and DC 7326, Crohn's Disease. In the proposed rule, VA listed
``distension'' under the evaluative criteria for the 20% and 30%
evaluations levels under DC 7319 and listed ``distention'' under the
10% evaluation level of DC 7319 and the 100% evaluation level of DC
7326. To ensure consistency, VA corrects this typographical error and
changes the
[[Page 19742]]
spelling at the 10% level under DC 7319 and the 100% evaluation under
DC 7326 to ``distension.''
VA makes two minor clerical corrections to DC 7330, Intestinal
fistulous disease, external at the 100% evaluation. VA amends the
evaluative language by replacing ``enteral nutrition'' with ``enteral
nutritional support.'' Additionally, VA specifies the size of the
ostomy bags by adding ``(sized 130cc).'' This language is consistent
with the 60% evaluative criteria under DC 7330. These changes do not
result in any substantive changes to the criteria under DC 7330.
VA makes two minor clerical corrections to DC 7351, Liver
transplant, at the 30 and 60-percent disability levels. To promote
clarity, VA amends the evaluative criteria for 30% disability rating by
adding the words ``Following transplant surgery,'' to the existing
language ``minimum rating.'' The minimum rating for liver transplant
surgery was applicable to the veterans with liver transplant. The
minimum rating's intent was to compensate veterans for post-transplant
functional impairment due to antirejection therapy and other liver
transplant medical management treatment modalities. Therefore, this
change to the language does not result in any substantive changes to
the criteria under DC 7351.
VA amends the evaluative criteria for a 60% disability rating by
replacing the word ``retransplantation'' with the words ``transplant
surgery,'' which is consistent with medical terminology that is
currently used to describe both first organ transplant surgery and any
subsequent organ transplant surgery. Additionally, VA adds the word
``eligible'' to the language ``awaiting'' to read ``Eligible and
awaiting transplant surgery, minimum rating.'' This clerical change
brings additional clarity to VA's intent in revising the rating
criteria for a 60% disability rating, which is to capture a specific
population of veterans who are awaiting liver transplant surgery and
who are eligible candidates for such surgery. This change to the
language does not result in any substantive changes to the criteria
under DC 7351.
VA noted a minor inconsistency in the use of the preposition
``with'' in the 30%, 50%, and 80% disability levels under DC 7355,
Celiac disease. At the 30% level, it reads, ``Malabsorption syndrome
with chronic diarrhea'', whereas at the 50% level it reads,
``Malabsorption syndrome that causes chronic diarrhea.'' To promote
clarity and consistency, VA amends the proposed text at the 50% level
by replacing ``that causes'' with the preposition ``with.'' The 50%
level now begins with the phrase, ``Malabsorption syndrome with chronic
diarrhea.'' To ensure standardization at all levels, VA makes a similar
amendment to the proposed text at the 80% level by replacing ``that
causes'' with the preposition ``with.'' The 80% level now begins with
the phrase, ``Malabsorption syndrome with weakness.'' This change to
the language does not result in any substantive changes to the criteria
under DC 7355, Celiac disease.
VA makes five clerical corrections under 38 CFR 4.114 for DCs 7301
Peritoneum, adhesions of, due to surgery, trauma, disease, or
infection, 7303 Chronic complications of upper gastrointestinal
surgery, 7328 Intestine, small, resection of, 7330 Intestinal fistulous
disease, external, and 7356 Gastrointestinal dysmotility syndrome. For
consistency and clarity, VA amends the evaluative language for each
occurrence where a total parenteral nutrition is mentioned. Throughout
its regulation, VA will refer to total parenteral nutrition as ``total
parenteral nutrition (TPN).'' These changes do not result in any
substantive changes to the criteria under DCs 7301, 7303, 7328, 7330,
and 7356.
Executive Orders 12866, 13563 and 14094
Executive Order 12866 (Regulatory Planning and Review) directs
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 14094 (Executive Order on
Modernizing Regulatory Review) supplements and reaffirms the
principles, structures, and definitions governing contemporary
regulatory review established in Executive Order 12866 of September 30,
1993 (Regulatory Planning and Review), and Executive Order 13563 of
January 18, 2011 (Improving Regulation and Regulatory Review). The
Office of Information and Regulatory Affairs has determined that this
rulemaking is a significant regulatory action under Executive Order
12866, section 3(f)(1), as amended by Executive Order 14094. The
Regulatory Impact Analysis associated with this rulemaking can be found
as a supporting document at www.regulations.gov.
Regulatory Flexibility Act
The Secretary hereby certifies that this final rule will 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). The factual basis for this certification is based on the fact
that small entities or businesses are not affected by revisions to the
VASRD.
Therefore, pursuant to 5 U.S.C. 605(b), the initial and final
regulatory flexibility analysis requirements of 5 U.S.C. 603 and 604 do
not apply.
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 final rule would have no such effect
on State, local, and tribal governments, or on the private sector.
Paperwork Reduction Act
This final rule contains no provisions constituting a collection of
information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).
Congressional Review Act
Under the Congressional Review Act, this regulatory action may
result in an annual effect on the economy of $100 million or more, 5
U.S.C. 804(2), and so is subject to the 60-day delay in effective date
under 5 U.S.C. 801(a)(3). In accordance with 5 U.S.C. 801(a)(1), VA
will submit to the Comptroller General and to Congress a copy of this
regulation and the Regulatory Impact Analysis (RIA) associated with the
regulation.
List of Subjects in 38 CFR Part 4
Disability benefits, Pensions, Veterans.
Signing Authority
Denis McDonough, Secretary of Veterans Affairs, approved and signed
this document on March 4, 2024, and authorized the undersigned to sign
and submit the document to the Office of the Federal Register for
publication
[[Page 19743]]
electronically as an official document of the Department of Veterans
Affairs.
Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of
General Counsel, Department of Veterans Affairs.
For the reasons set out in the preamble, VA amends 38 CFR part 4 as
set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
0
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
Sec. 4.110 [Removed and Reserved]
0
2. Remove and reserve Sec. 4.110.
Sec. 4.111 [Removed and Reserved]
0
3. Remove and reserve Sec. 4.111.
0
4. Revise Sec. 4.112 to read as follows:
Sec. 4.112 Weight loss and nutrition.
The following terms apply when evaluating conditions in Sec.
4.114:
(a) Weight loss. Substantial weight loss means involuntary loss
greater than 20% of an individual's baseline weight sustained for three
months with diminished quality of self-care or work tasks. The term
minor weight loss means involuntary weight loss between 10% and 20% of
an individual's baseline weight sustained for three months with
gastrointestinal-related symptoms, involving diminished quality of
self-care or work tasks, or decreased food intake. The term inability
to gain weight means substantial weight loss with the inability to
regain it despite following appropriate therapy.
(b) Baseline weight. Baseline weight means the clinically
documented average weight for the two-year period preceding the onset
of illness or, if relevant, the weight recorded at the veteran's most
recent discharge physical. If neither of these weights is available or
currently relevant, then use ideal body weight as determined by either
the Hamwi formula or Body Mass Index tables, whichever is most
favorable to the veteran.
(c) Undernutrition. Undernutrition means a deficiency resulting
from insufficient intake of one or multiple essential nutrients, or the
inability of the body to absorb, utilize, or retain such nutrients.
Undernutrition is characterized by failure of the body to maintain
normal organ functions and healthy tissues. Signs and symptoms may
include loss of subcutaneous tissue, edema, peripheral neuropathy,
muscle wasting, weakness, abdominal distention, ascites, and Body Mass
Index below normal range.
(d) Nutritional support. Paragraphs (d)(1) and (2) of this section
describe various nutritional support methods used to treat certain
digestive conditions.
(1) Total parenteral nutrition (TPN) or hyperalimentation is a
special liquid mixture given into the blood through an intravenous
catheter. The mixture contains proteins, carbohydrates (sugars), fats,
vitamins, and minerals. TPN bypasses the normal digestion in the
stomach and bowel.
(2) Assisted enteral nutrition requires a special liquid mixture
(containing proteins, carbohydrates (sugar), fats, vitamins, and
minerals) to be delivered into the stomach or bowel through a flexible
feeding tube. Percutaneous endoscopic gastrostomy is a type of assisted
enteral nutrition in which a flexible feeding tube is inserted through
the abdominal wall and into the stomach. Nasogastric or nasoenteral
feeding tube is a type of assisted parenteral nutrition in which a
flexible feeding tube is inserted through the nose into the stomach or
bowel.
0
5. Amends Sec. 4.114 by:
0
a. Revising the introductory text and the entries for diagnostic codes
7200 through 7205;
0
b. Adding in numerical order entries for diagnostic codes 7206 and
7207;
0
c. Revising the entry for diagnostic code 7301;
0
d. Adding in numerical order an entry for diagnostic code 7303;
0
e. Revising the entry for diagnostic code 7304;
0
f. Removing the entries for diagnostic codes 7305 and 7306;
0
g. Revising the entries for diagnostic codes 7307 through 7310, 7312,
7314, and 7315;
0
h. Removing the entry for diagnostic code 7316;
0
i. Revising the entries for diagnostic codes 7317 through 7319;
0
j. Removing the entries for diagnostic codes 7321 and 7322;
0
k. Revising the entry for diagnostic code 7323;
0
l. Removing the entry for diagnostic code 7324;
0
m. Revising the entries for diagnostic codes 7325 through 7330 and 7332
through 7338;
0
n. Removing the entries for diagnostic codes 7339 and 7340;
0
o. Revising the entries for diagnostic codes 7344 through 7348;
0
p. Adding in numerical order an entry for diagnostic code 7350;
0
q. Revising the entry for diagnostic code 7351;
0
r. Adding in numerical order an entry for diagnostic code 7352;
0
s. Revising the entry for diagnostic code 7354; and
0
t. Adding in numerical order entries for diagnostic codes 7355 through
7357.
The revisions and additions read as follows:
Sec. 4.114 Schedule of ratings--digestive system.
Do not combine ratings under diagnostic codes 7301 through 7329
inclusive, 7331, 7342, 7345 through 7350 inclusive, 7352, and 7355
through 7357 inclusive, with each other. Instead, when more than one
rating is warranted under those diagnostic codes, assign a single
evaluation under the diagnostic code that reflects the predominant
disability picture, and elevate it to the next higher evaluation if
warranted by the severity of the overall disability.
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
7200 Soft tissue injury of the mouth, other than tongue
or lips:
Rate as for disfigurement (diagnostic codes 7800 and
7804) and impairment of mastication.
7201 Lips, injuries of:
Rate as disfigurement (diagnostic codes 7800 and
7804).
7202 Tongue, loss of whole or part:
Absent oral nutritional intake...................... 100
Intact oral nutritional intake with permanently 60
impaired swallowing function that requires
prescribed dietary modification....................
Intact oral nutritional intake with permanently 30
impaired swallowing function without prescribed
dietary modification...............................
Note (1): Rate the residuals of speech impairment as
complete organic aphonia (DC 6519) or incomplete
aphonia as laryngitis, chronic (DC 6516).
Note (2): Dietary modifications due to this
condition must be prescribed by a medical provider.
7203 Esophagus, stricture of:
[[Page 19744]]
Documented history of recurrent or refractory 80
esophageal stricture(s) causing dysphagia with at
least one of the symptoms present: (1) aspiration,
(2) undernutrition, and/or (3) substantial weight
loss as defined by Sec. 4.112(a) and treatment
with either surgical correction or percutaneous
esophago-gastrointestinal tube (PEG tube)..........
Documented history of recurrent or refractory 50
esophageal stricture(s) causing dysphagia which
requires at least one of the following (1)
dilatation 3 or more times per year, (2) dilatation
using steroids at least one time per year, or (3)
esophageal stent placement.........................
Documented history of recurrent esophageal 30
stricture(s) causing dysphagia which requires
dilatation no more than 2 times per year...........
Documented history of esophageal stricture(s) that 10
requires daily medications to control dysphagia
otherwise asymptomatic.............................
Documented history without daily symptoms or 0
requirement for daily medications..................
Note (1): Findings must be documented by barium
swallow, computerized tomography, or
esophagogastroduodenoscopy.
Note (2): Non-gastrointestinal complications of
procedures should be rated under the appropriate
system.
Note (3): This diagnostic code applies, but is not
limited to, esophagitis, mechanical or chemical;
Mallory Weiss syndrome (bleeding at junction of
esophagus and stomach due to tears) due to caustic
ingestion of alkali or acid; drug-induced or
infectious esophagitis due to Candida, virus, or
other organism; idiopathic eosinophilic, or
lymphocytic esophagitis; esophagitis due to
radiation therapy; esophagitis due to peptic
stricture; and any esophageal condition that
requires treatment with sclerotherapy.
Note (4): Recurrent esophageal stricture is defined
as the inability to maintain target esophageal
diameter beyond 4 weeks after the target diameter
has been achieved.
Note (5): Refractory esophageal stricture is defined
as the inability to achieve target esophageal
diameter despite receiving no fewer than 5
dilatation sessions performed at 2-week intervals.
7204 Esophageal motility disorder:
Rate as esophagus, stricture of (DC 7203).
Note: This diagnostic code applies, but is not
limited to, achalasia (cardiospasm), diffuse
esophageal spasm (DES), corkscrew esophagus,
nutcracker esophagus, and other motor disorders of
the esophagus; esophageal rings (including Schatzki
rings), mucosal webs or folds, and impairment of
the esophagus caused by systemic conditions such as
myasthenia gravis, scleroderma, and other
neurologic conditions.
7205 Esophagus, diverticulum of, acquired:
Rate as esophagus, stricture of (DC 7203).
Note: This diagnostic code, applies, but is not
limited to, pharyngo- esophageal (Zenker's)
diverticulum, mid-esophageal diverticulum, and
epiphrenic (distal esophagus) diverticulum.
7206 Gastroesophageal reflux disease:
Documented history of recurrent or refractory 80
esophageal stricture(s) causing dysphagia with at
least one of the symptoms present: (1) aspiration,
(2) undernutrition, and/or (3) substantial weight
loss as defined by Sec. 4.112(a) and treatment
with either surgical correction of esophageal
stricture(s) or percutaneous esophago-
gastrointestinal tube (PEG tube)...................
Documented history of recurrent or refractory 50
esophageal stricture(s) causing dysphagia which
requires at least one of the following (1)
dilatation 3 or more times per year, (2) dilatation
using steroids at least one time per year, or (3)
esophageal stent placement.........................
Documented history of recurrent esophageal 30
stricture(s) causing dysphagia which requires
dilatation no more than 2 times per year...........
Documented history of esophageal stricture(s) that 10
requires daily medications to control dysphagia
otherwise asymptomatic.............................
Documented history without daily symptoms or 0
requirement for daily medications..................
Note (1): Findings must be documented by barium
swallow, computerized tomography, or
esophagogastroduodenoscopy.
Note (2): Non-gastrointestinal complications of
procedures should be rated under the appropriate
system.
Note (3): This diagnostic code applies, but is not
limited to, esophagitis, mechanical or chemical;
Mallory Weiss syndrome (bleeding at junction of
esophagus and stomach due to tears) due to caustic
ingestion of alkali or acid; drug-induced or
infectious esophagitis due to Candida, virus, or
other organism; idiopathic eosinophilic, or
lymphocytic esophagitis; esophagitis due to
radiation therapy; esophagitis due to peptic
stricture; and any esophageal condition that
requires treatment with sclerotherapy.
Note (4): Recurrent esophageal stricture is defined
as the inability to maintain target esophageal
diameter beyond 4 weeks after the target diameter
has been achieved.
Note (5): Refractory esophageal stricture is defined
as the inability to achieve target esophageal
diameter despite receiving no fewer than 5
dilatation sessions performed at 2-week intervals.
7207 Barrett's esophagus:
With esophageal stricture: Rate as esophagus,
stricture of (DC 7203).
Without esophageal stricture:
Documented by pathologic diagnosis with high-grade 30
dysplasia..........................................
Documented by pathologic diagnosis with low-grade 10
dysplasia..........................................
Note (1): If malignancy develops, rate as malignant
neoplasms of the digestive system, exclusive of
skin growths (DC 7343).
Note (2): If the condition is resolved via surgery,
radiofrequency ablation, or other treatment, rate
residuals as esophagus, stricture of (DC 7203).
7301 Peritoneum, adhesions of, due to surgery, trauma,
disease, or infection:
Persistent partial bowel obstruction that is either 80
inoperable and refractory to treatment, or requires
total parenteral nutrition (TPN) for obstructive
symptoms...........................................
Symptomatic peritoneal adhesions, persisting or 50
recurring after surgery, trauma, inflammatory
disease process such as chronic cholecystitis or
Crohn's disease, or infection, as determined by a
healthcare provider; and clinical evidence of
recurrent obstruction requiring hospitalization at
least once a year; and medically-directed dietary
modification other than total parenteral nutrition
(TPN); and at least one of the following: (1)
abdominal pain, (2) nausea, (3) vomiting, (4)
colic, (5) constipation, or (6) diarrhea...........
Symptomatic peritoneal adhesions, persisting or 30
recurring after surgery, trauma, inflammatory
disease process such as chronic cholecystitis or
Crohn's disease, or infection, as determined by a
healthcare provider; and medically-directed dietary
modification other than total parenteral nutrition
(TPN); and at least one of the following: (1)
abdominal pain, (2) nausea, (3) vomiting, (4)
colic, (5) constipation, or (6) diarrhea...........
[[Page 19745]]
Symptomatic peritoneal adhesions, persisting or 10
recurring after surgery, trauma, inflammatory
disease process such as chronic cholecystitis or
Crohn's disease, or infection, as determined by a
healthcare provider, and at least one of the
following: (1) abdominal pain, (2) nausea, (3)
vomiting, (4) colic, (5) constipation, or (6)
diarrhea...........................................
History of peritoneal adhesions, currently 0
asymptomatic.......................................
7303 Chronic complications of upper gastrointestinal
surgery:
Requiring continuous total parenteral nutrition 80
(TPN) or tube feeding for a period longer than 30
consecutive days in the last six months............
Any one of the following symptoms with or without 50
pain: (1) daily vomiting despite oral dietary
modification or medication; (2) six or more watery
bowel movements per day every day, or explosive
bowel movements that are difficult to predict or
control; (3) post-prandial (meal-induced) light-
headedness (syncope) with sweating and the need for
medications to specifically treat complications of
upper gastrointestinal surgery such as dumping
syndrome or delayed gastric emptying...............
With two or more of the following symptoms: (1) 30
vomiting two or more times per week or vomiting
despite medical treatment; (2) discomfort or pain
within an hour of eating and requiring ongoing oral
dietary modification; (3) three to five watery
bowel movements per day every day..................
With either nausea or vomiting managed by ongoing 10
medical treatment..................................
Post-operative status, asymptomatic................. 0
Note (1): For resection of small intestine, use DC
7328.
Note (2): If pancreatic surgery results in a vitamin
or mineral deficiency (e.g., B12, iron, calcium, or
fat-soluble vitamins), evaluate under the
appropriate vitamin/mineral deficiency code and
assign the higher rating. For example, evaluate
Vitamin A, B, C or D deficiencies under DC 6313;
ocular manifestations of vitamin deficiencies, such
as night blindness, under DC 6313; keratitis or
keratomalacia due to Vitamin A deficiency under DC
6001; Vitamin E deficiency under neuropathy; and
Vitamin K deficiency under prolonged clotting
(e.g., DC 7705).
Note (3): This diagnostic code includes operations
performed on the esophagus, stomach, pancreas, and
small intestine, including bariatric surgery.
7304 Peptic ulcer disease:
Post-operative for perforation or hemorrhage, for 100
three months.......................................
Continuous abdominal pain with intermittent 60
vomiting, recurrent hematemesis (vomiting blood) or
melena (tarry stools); and manifestations of anemia
which require hospitalization at least once in the
past 12 months.....................................
Episodes of abdominal pain, nausea, or vomiting, 40
that: last for at least three consecutive days in
duration; occur four or more times in the past 12
months; and are managed by daily prescribed
medication.........................................
Episodes of abdominal pain, nausea, or vomiting, 20
that: last for at least three consecutive days in
duration; occur three times or less in the past 12
months; and are managed by daily prescribed
medication.........................................
History of peptic ulcer disease documented by 0
endoscopy or diagnostic imaging studies............
Note: After three months at the 100% evaluation,
rate on residuals as determined by mandatory VA
medical examination. Apply the provisions of Sec.
3.105(e) of this chapter to any change in
evaluation based upon that or any subsequent
examination.
7307 Gastritis, chronic:
Rate as peptic ulcer disease (DC 7304).
Note: This diagnostic code includes Helicobacter
pylori infection, drug-induced gastritis, Zollinger-
Ellison syndrome, and portal-hypertensive
gastropathy with varix-related complications.
7308 Postgastrectomy syndrome:
Rate residuals as chronic complications of upper
gastrointestinal surgery (DC 7303).
7309 Stomach, stenosis of:
Rate as chronic complications of upper
gastrointestinal surgery (DC 7303) or peptic ulcer
disease (DC 7304), depending on the predominant
disability.
7310 Stomach, injury of, residuals:
Pre-operative: Rate as adhesions of peritoneum due
to surgery, trauma, disease, or infection (DC
7301). No adhesions are necessary when evaluating
under DC 7301.
Post-operative: Rate as chronic complications of
upper gastrointestinal surgery (DC 7303).
* * * * * * *
7312 Cirrhosis of the liver:
Liver disease with Model for End-Stage Liver Disease 100
score greater than or equal to 15; or with
continuous daily debilitating symptoms, generalized
weakness and at least one of the following: (1)
ascites (fluid in the abdomen), or (2) a history of
spontaneous bacterial peritonitis, or (3) hepatic
encephalopathy, or (4) variceal hemorrhage, or (5)
coagulopathy, or (6) portal gastropathy, or (7)
hepatopulmonary or hepatorenal syndrome............
Liver disease with Model for End-Stage Liver Disease 60
score greater than 11 but less than 15; or with
daily fatigue and at least one episode in the last
year of either (1) variceal hemorrhage, or (2)
portal gastropathy or hepatic encephalopathy.......
Liver disease with Model for End-Stage Liver Disease 30
score of 10 or 11; or with signs of portal
hypertension such as splenomegaly or ascites (fluid
in the abdomen) and either weakness, anorexia,
abdominal pain, or malaise.........................
Liver disease with Model for End-Stage Liver Disease 10
score greater than 6 but less than 10; or with
evidence of either anorexia, weakness, abdominal
pain or malaise....................................
Asymptomatic, but with a history of liver disease... 0
Note (1): Rate hepatocellular carcinoma occurring
with cirrhosis under DC 7343 (Malignant neoplasms
of the digestive system, exclusive of skin growths)
in lieu of DC 7312.
Note (2): Biochemical studies, imaging studies, or
biopsy must confirm liver dysfunction (including
hyponatremia, thrombocytopenia, and/or
coagulopathy).
Note (3): Rate condition based on symptomatology
where the evidence does not contain a Model for End-
Stage Liver Disease score.
7314 Chronic biliary tract disease:
With three or more clinically documented attacks of 30
right upper quadrant pain with nausea and vomiting
during the past 12 months; or requiring dilatation
of biliary tract strictures at least once during
the past 12 months.
With one or two clinically documented attacks of 10
right upper quadrant pain with nausea and vomiting
in the past 12 months.
[[Page 19746]]
Asymptomatic, without history of a clinically 0
documented attack of right upper quadrant pain with
nausea and vomiting in the past 12 months.
Note: This diagnostic code includes cholangitis,
biliary strictures, Sphincter of Oddi dysfunction,
bile duct injury, and choledochal cyst. Rate
primary sclerosing cholangitis under chronic liver
disease without cirrhosis (DC 7345).
7315 Cholelithiasis, chronic:
Rate as chronic biliary tract disease (DC 7314).
7317 Gallbladder, injury of:
Rate as adhesions of the peritoneum due to surgery,
trauma, disease, or infection (DC 7301); or chronic
gallbladder and biliary tract disease (DC 7314), or
cholecystectomy (gallbladder removal),
complications of (such as strictures and biliary
leaks) (DC 7318), depending on the predominant
disability.
Note: When rating gallbladder injuries analogous to
DC 7301, a finding of adhesions is not necessary.
7318 Cholecystectomy (gallbladder removal),
complications of (such as strictures and biliary
leaks):
With recurrent abdominal pain (post-prandial or 30
nocturnal); and chronic diarrhea characterized by
three or more watery bowel movements per day.......
With intermittent abdominal pain; and diarrhea 10
characterized by one to two watery bowel movements
per day............................................
Asymptomatic........................................ 0
7319 Irritable bowel syndrome (IBS):
Abdominal pain related to defecation at least one 30
day per week during the previous three months; and
two or more of the following: (1) change in stool
frequency, (2) change in stool form, (3) altered
stool passage (straining and/or urgency), (4)
mucorrhea, (5) abdominal bloating, or (6)
subjective distension..............................
Abdominal pain related to defecation for at least 20
three days per month during the previous three
months; and two or more of the following: (1)
change in stool frequency, (2) change in stool
form, (3) altered stool passage (straining and/or
urgency), (4) mucorrhea, (5) abdominal bloating, or
(6) subjective distension..........................
Abdominal pain related to defecation at least once 10
during the previous three months; and two or more
of the following: (1) change in stool frequency,
(2) change in stool form, (3) altered stool passage
(straining and/or urgency), (4) mucorrhea, (5)
abdominal bloating, or (6) subjective distension...
Note: This diagnostic code may include functional
digestive disorders (see Sec. 3.317 of this
chapter), such as dyspepsia, functional bloating
and constipation, and diarrhea. Evaluate other
symptoms of a functional digestive disorder not
encompassed by this diagnostic code under the
appropriate diagnostic code, to include
gastrointestinal dysmotility syndrome (DC 7356),
following the general principles of Sec. 4.14 and
this section.
7323 Colitis, ulcerative:
Rate as Crohn's disease or undifferentiated form of
inflammatory bowel disease (DC 7326).
7325 Enteritis, chronic:
Rate as Irritable Bowel Syndrome (DC 7319) or
Crohn's disease or undifferentiated form of
inflammatory bowel disease (DC 7326), depending on
the predominant disability.
7326 Crohn's disease or undifferentiated form of
inflammatory bowel disease:
Severe inflammatory bowel disease that is 100
unresponsive to treatment; and requires
hospitalization at least once per year; and results
in either an inability to work or is characterized
by recurrent abdominal pain associated with at
least two of the following: (1) six or more
episodes per day of diarrhea, (2) six or more
episodes per day of rectal bleeding, (3) recurrent
episodes of rectal incontinence, or (4) recurrent
abdominal distension...............................
Moderate inflammatory bowel disease that is managed 60
on an outpatient basis with immunosuppressants or
other biologic agents; and is characterized by
recurrent abdominal pain, four to five daily
episodes of diarrhea; and intermittent signs of
toxicity such as fever, tachycardia, or anemia.....
Mild to moderate inflammatory bowel disease that is 30
managed with oral and topical agents (other than
immunosuppressants or other biologic agents); and
is characterized by recurrent abdominal pain with
three or less daily episodes of diarrhea and
minimal signs of toxicity such as fever,
tachycardia, or anemia.............................
Minimal to mild symptomatic inflammatory bowel 10
disease that is managed with oral or topical agents
(other than immunosuppressants or other biologic
agents); and is characterized by recurrent
abdominal pain with three or less daily episodes of
diarrhea and no signs of systemic toxicity.........
Note (1): Following colectomy/colostomy with
persistent or recurrent symptoms, rate either under
DC 7326 or DC 7329 (Intestine, large, resection
of), whichever provides the highest rating.
Note (2): VA requires diagnoses under DC 7326 to be
confirmed by endoscopy or radiologic studies.
Note (3): Inflammation may involve small bowel
(ileitis), large bowel (colitis), or inflammation
of any component of the gastrointestinal tract from
the mouth to the anus.
7327 Diverticulitis and diverticulosis:
Diverticular disease requiring hospitalization for 30
abdominal distress, fever, and leukocytosis
(elevated white blood cells) one or more times in
the past 12 months; and with at least one of the
following complications: (1) hemorrhage, (2)
obstruction, (3) abscess, (4) peritonitis, or (5)
perforation........................................
Diverticular disease requiring hospitalization for 20
abdominal distress, fever, and leukocytosis
(elevated white blood cells) one or more times in
the past 12 months; and without associated (1)
hemorrhage, (2) obstruction, (3) abscess, (4)
peritonitis, or (5) perforation....................
Asymptomatic; or a symptomatic diverticulitis or 0
diverticulosis that is managed by diet and
medication.........................................
Note: For colectomy or colostomy, use DC 7327 or DC
7329 (Intestine, large, resection of), whichever
results in a higher evaluation.
7328 Intestine, small, resection of:
Status post intestinal resection with undernutrition 80
and anemia; and requiring total parenteral
nutrition (TPN)....................................
Status post intestinal resection with undernutrition 60
and anemia; and requiring prescribed oral dietary
supplementation, continuous medication and
intermittent total parenteral nutrition (TPN)......
Status post intestinal resection with four or more 40
episodes of diarrhea per day resulting in
undernutrition and anemia; and requiring prescribed
oral dietary supplementation and continuous
medication.........................................
Status post intestinal resection with four or more 20
episodes of diarrhea per day.......................
Status post intestinal resection, asymptomatic...... 0
[[Page 19747]]
Note: This diagnostic code includes short bowel
syndrome, mesenteric ischemic thrombosis, and post-
bariatric surgery complications. Where short bowel
syndrome results in high-output syndrome, to
include high-output stoma, consider assigning a
higher evaluation under DC 7329 (Intestine, large,
resection of).
7329 Intestine, large, resection of:
Total colectomy with formation of ileostomy, high- 100
output syndrome, and more than two episodes of
dehydration requiring intravenous hydration in the
past 12 months.....................................
Total colectomy with or without permanent colostomy 60
or ileostomy without high-output syndrome..........
Partial colectomy with permanent colostomy or 40
ileostomy without high-output syndrome.............
Partial colectomy with reanastomosis (reconnection 20
of the intestinal tube) with loss of ileocecal
valve and recurrent episodes of diarrhea more than
3 times per day....................................
Partial colectomy with reanastomosis (reconnection 10
of the intestinal tube)............................
7330 Intestinal fistulous disease, external:
Requiring total parenteral nutrition (TPN); or 100
enteral nutritional support along with at least one
of the following: (1) daily discharge equivalent to
four or more ostomy bags (sized 130 cc), (2)
requiring ten or more pad changes per day, or (3) a
Body Mass Index (BMI) less than 16 and persistent
drainage (any amount) for more than 1 month during
the past 12 months.................................
Requiring enteral nutritional support along with at 60
least one of the following: (1) daily discharge
equivalent to three or less ostomy bags (sized 130
cc), (2) requiring fewer than ten pad changes per
day, or (3) a Body Mass Index (BMI) of 16 to 18
inclusive and persistent drainage (any amount) for
more than 2 months in the past 12 months...........
Intermittent fecal discharge with persistent 30
drainage for more than 3 months in the past 12
months.............................................
Note: This code applies to external fistulas that
have developed as a consequence of abdominal
trauma, surgery, radiation, malignancy, infection,
or ischemia.
* * * * * * *
7332 Rectum and anus, impairment of sphincter control:
Complete loss of sphincter control characterized by 100
incontinence or retention that is not responsive to
a physician-prescribed bowel program and requires
either surgery or digital stimulation, medication
(beyond laxative use), and special diet; or
incontinence to solids and/or liquids two or more
times per day, which requires changing a pad two or
more times per day.................................
Complete or partial loss of sphincter control 60
characterized by incontinence or retention that is
partially responsive to a physician-prescribed
bowel program and requires either surgery or
digital stimulation, medication (beyond laxative
use), and special diet; or incontinence to solids
and/or liquids two or more times per week, which
requires wearing a pad two or more times per week..
Complete or partial loss of sphincter control 30
characterized by incontinence or retention that is
fully responsive to a physician-prescribed bowel
program and requires digital stimulation,
medication (beyond laxative use), and special diet;
or incontinence to solids and/or liquids two or
more times per month, which requires wearing a pad
two or more times per month........................
Complete or partial loss of sphincter control 10
characterized by incontinence or retention that is
fully responsive to a physician-prescribed bowel
program and requires medication or special diet; or
incontinence to solids and/or liquids at least once
every six months, which requires wearing a pad at
least once every six months........................
History of loss of sphincter control, currently 0
asymptomatic.......................................
Note: Complete or partial loss of sphincter control
refers to the inability to retain or expel stool at
an appropriate time and place.
7333 Rectum and anus, stricture of:
Inability to open the anus with inability to expel 100
solid feces........................................
Reduction of the lumen 50% or more, with pain and 60
straining during defecation........................
Reduction of the lumen by less than 50%, with 30
straining during defecation........................
Luminal narrowing with or without straining, managed 10
by dietary intervention............................
Note (1): Conditions rated under this code include
dyssynergic defecation (levator ani) and anismus
(functional constipation)..........................
Note (2): Evaluate an ostomy as Intestine, large,
resection of (DC 7329).............................
7334 Rectum, prolapse of:
Persistent irreducible prolapse, repairable or 100
unrepairable.......................................
Manually reducible prolapse that is not repairable 50
and occurs at times other than bowel movements,
exertion, or while performing the Valsalva maneuver
Manually reducible prolapse that is not repairable 30
and occurs only after bowel movements, exertion, or
while performing the Valsalva maneuver.............
Spontaneously reducible prolapse that is not 10
repairable.........................................
Note (1): For repairable prolapse of the rectum,
continue the 100% evaluation for two months
following repair. Thereafter, determine the
appropriate evaluation based on residuals by
mandatory VA examination. Apply the provisions of
Sec. 3.105(e) of this chapter to any change in
evaluation based upon that or any subsequent
examination.
Note (2): Where impairment of sphincter control
constitutes the predominant disability, rate under
diagnostic code 7332 (Rectum and anus, impairment
of sphincter control).
7335 Ano, fistula in, including anorectal fistula and
anorectal abscess:
More than two constant or near-constant fistulas 60
with abscesses, drainage, and pain, which are
refractory to medical and surgical treatment.......
One or two simultaneous fistulas, with abscess, 40
drainage, and pain.................................
Two or more simultaneous fistulas with drainage and 20
pain, but without abscesses........................
One fistula with drainage and pain, but without 10
abscess............................................
7336 Hemorrhoids, external or internal:
Internal or external hemorrhoids with persistent 20
bleeding and anemia; or continuously prolapsed
internal hemorrhoids with three or more episodes
per year of thrombosis.............................
Prolapsed internal hemorrhoids with two or less 10
episodes per year of thrombosis; or external
hemorrhoids with three or more episodes per year of
thrombosis.........................................
[[Page 19748]]
7337 Pruritus ani (anal itching):
With bleeding or excoriation........................ 10
Without bleeding or excoriation..................... 0
7338 Hernia, including femoral, inguinal, umbilical,
ventral, incisional, and other (but not including
hiatal).
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present
for 12 months or more:
1. Size equal to 15 cm or greater in one dimension;
and
2. Pain when performing at least three of the 100
following activities: (1) bending over, (2)
activities of daily living (ADLs), (3) walking, and
(4) climbing stairs................................
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present
for 12 months or more:
1. Size equal to 15 cm or greater in one dimension;
and
2. Pain when performing two of the following 60
activities: (1) bending over, (2) activities of
daily living (ADLs), (3) walking, and (4) climbing
stairs.............................................
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present
for 12 months or more:
1. Size equal to 3 cm or greater but less than 15 cm
in one dimension; and
2. Pain when performing at least two of the 30
following activities: (1) bending over, (2)
activities of daily living (ADLs), (3) walking, and
(4) climbing stairs................................
Irreparable hernia (new or recurrent) present for 12
months or more; with both of the following present
for 12 months or more:
1. Size equal to 3 cm or greater but less than 15 cm
in one dimension; and
2. Pain when performing one of the following 20
activities: (1) bending over, (2) activities of
daily living (ADLs), (3) walking, and (4) climbing
stairs.............................................
Irreparable hernia (new or recurrent) present for 12 10
months or more; with hernia size smaller than 3 cm.
Asymptomatic hernia; present and repairable, or 0
repaired...........................................
Note (1): With two compensable inguinal hernias,
evaluate the more severely disabling hernia first,
and then add 10% to that rating to account for the
second compensable hernia. Do not add 10% to that
rating if the more severely disabling hernia is
rated at 100%.
Note (2): Any one of the following activities of
daily living are sufficient for evaluation:
bathing, dressing, hygiene, and/or transfers.
* * * * * * *
7344 Benign neoplasms, exclusive of skin growths:
Evaluate under a diagnostic code appropriate to the
predominant disability or the specific residuals
after treatment.
Note: This diagnostic code includes lipoma,
leiomyoma, colon polyps, or villous adenoma.
7345 Chronic liver disease without cirrhosis:
Progressive chronic liver disease requiring use of 100
both parenteral antiviral therapy (direct antiviral
agents), and parenteral immunomodulatory therapy
(interferon and other); and for six months
following discontinuance of treatment..............
Progressive chronic liver disease requiring 60
continuous medication and causing substantial
weight loss and at least two of the following: (1)
daily fatigue, (2) malaise, (3) anorexia, (4)
hepatomegaly, (5) pruritus, and (6) arthralgia.....
Progressive chronic liver disease requiring 40
continuous medication and causing minor weight loss
and at least two of the following: (1) daily
fatigue, (2) malaise, (3) anorexia, (4)
hepatomegaly, (5) pruritus, and (6) arthralgia.....
Chronic liver disease with at least one of the 20
following: (1) intermittent fatigue, (2) malaise,
(3) anorexia, (4) hepatomegaly, or (5) pruritus....
Previous history of liver disease, currently 0
asymptomatic.......................................
Note (1): 100% evaluation shall continue for six
months following discontinuance of parenteral
antiviral therapy and administration of parenteral
immunomodulatory drugs. Six months after
discontinuance of parenteral antiviral therapy and
parenteral immunomodulatory drugs, determine the
appropriate disability rating by mandatory VA exam.
Apply the provisions of Sec. 3.105(e) of this
chapter to any change in evaluation based upon that
or any subsequent examination.
Note (2): For individuals for whom physicians
recommend both parenteral antiviral therapy and
parenteral immunomodulatory drugs, but for whom
treatment is medically contraindicated, rate
according to DC 7312 (Cirrhosis of the liver).
Note (3): This diagnostic code includes Hepatitis B
(confirmed by serologic testing), primary biliary
cirrhosis (PBC), primary sclerosing cholangitis
(PSC), autoimmune liver disease, Wilson's disease,
Alpha-1-antitrypsin deficiency, hemochromatosis,
drug-induced hepatitis, and non-alcoholic
steatohepatitis (NASH). Track Hepatitis C (or non-
A, non-B hepatitis) under DC 7354 but evaluate it
using the criteria in this entry.
Note (4): Evaluate sequelae, such as cirrhosis or
malignancy of the liver, under an appropriate
diagnostic code, but do not use the same signs and
symptoms as the basis for evaluation under DC 7354
and under a diagnostic code for sequelae. (See Sec.
4.14)
7346 Hiatal hernia and paraesophageal hernia:
Rate as esophagus, stricture of (DC 7203).
7347 Pancreatitis, chronic:
Daily episodes of abdominal or mid-back pain that 100
require three or more hospitalizations per year;
and pain management by a physician; and
maldigestion and malabsorption requiring dietary
restriction and pancreatic enzyme supplementation..
Three or more episodes of abdominal or mid-back pain 60
per year and at least one episode per year
requiring hospitalization for management either of
complications related to abdominal pain or
complications of tube enteral feeding..............
At least one episode per year of abdominal or mid- 30
back pain that requires ongoing outpatient medical
treatment for pain, digestive problems, or
management of related complications including but
not limited to cyst, pseudocyst, intestinal
obstruction, or ascites............................
Note (1): Appropriate diagnostic studies must
confirm that abdominal pain in this condition
results from pancreatitis.
Note (2): Separately rate endocrine dysfunction
resulting in diabetes due to pancreatic
insufficiency under DC 7913 (Diabetes mellitus).
7348 Vagotomy with pyloroplasty or gastroenterostomy:
[[Page 19749]]
Following confirmation of postoperative 40
complications of stricture or continuing gastric
retention..........................................
With symptoms and confirmed diagnosis of alkaline 30
gastritis, or with confirmed persisting diarrhea...
With incomplete vagotomy............................ 20
Note: Rate recurrent ulcer following complete
vagotomy under DC 7304 (Peptic ulcer disease), with
a minimum rating of 20%; and rate post-operative
residuals not addressed by this diagnostic code
under DC 7303 (Chronic complications of upper
gastrointestinal surgery).
7350 Liver abscess:
Assign a rating of 100% for 6 months from the date
of initial diagnosis. Six months following initial
diagnosis, determine the appropriate disability
rating by mandatory VA examination. Thereafter,
rate the condition based on chronic residuals under
the appropriate body system. Apply the provisions
of Sec. 3.105(e) of this chapter to any reduction
in evaluation.
Note: This diagnostic code includes abscesses caused
by bacterial, viral, amebic (e.g., E. hystolytica),
fungal (e.g., C. albicans), and other agents.
7351 Liver transplant:
For an indefinite period from the date of hospital 100
admission for transplant surgery...................
Eligible and awaiting transplant surgery, minimum 60
rating.............................................
Following transplant surgery, minimum rating........ 30
Note: Assign a rating of 100% as of the date of
hospital admission for transplant surgery. One year
following discharge, determine the appropriate
disability rating by mandatory VA examination.
Apply the provisions of Sec. 3.105(e) of this
chapter to any change in evaluation based upon that
or any subsequent examination. Rate residuals of
any recurrent underlying liver disease under the
appropriate diagnostic code and, when appropriate,
combine with other post-transplant residuals under
the appropriate body system(s), subject to the
provisions of Sec. 4.14 and this section.
7352 Pancreas transplant:
For an indefinite period from the date of hospital 100
admission for transplant surgery...................
Minimum rating...................................... 30
Note: Assign a rating of 100% as of the date of
hospital admission for transplant surgery. One year
following discharge, determine the appropriate
disability rating by mandatory VA examination.
Apply the provisions of Sec. 3.105(e) of this
chapter to any change in evaluation based upon that
or any subsequent examination.
7354 Hepatitis C (or non-A, non-B hepatitis):
Rate under DC 7345 (Chronic liver disease without
cirrhosis).
7355 Celiac disease:
Malabsorption syndrome with weakness which 80
interferes with activities of daily living; and
weight loss resulting in wasting and nutritional
deficiencies; and with systemic manifestations
including but not limited to, weakness and fatigue,
dermatitis, lymph node enlargement, hypocalcemia,
low vitamin levels; and anemia related to
malabsorption; and episodes of abdominal pain and
diarrhea due to lactase deficiency or pancreatic
insufficiency......................................
Malabsorption syndrome with chronic diarrhea managed 50
by medically-prescribed dietary intervention such
as prescribed gluten-free diet, with nutritional
deficiencies due to lactase and pancreatic
insufficiency; and with systemic manifestations
including, but not limited to, weakness and
fatigue, dermatitis, lymph node enlargement,
hypocalcemia, low vitamin levels, or atrophy of the
inner intestinal lining shown on biopsy............
Malabsorption syndrome with chronic diarrhea managed 30
by medically-prescribed dietary intervention such
as prescribed gluten-free diet; and without
nutritional deficiencies...........................
Note (1): An appropriate serum antibody test or
endoscopy with biopsy must confirm the diagnosis.
Note (2): For evaluation of celiac disease with the
predominant disability of malabsorption, use the
greater evaluation between DC 7328 or celiac
disease under DC 7355.
7356 Gastrointestinal dysmotility syndrome:
Requiring complete dependence on total parenteral 80
nutrition (TPN) or continuous tube feeding for
nutritional support................................
Requiring intermittent tube feeding for nutritional 50
support; with recurrent emergency treatment for
episodes of intestinal obstruction or regurgitation
due to poor gastric emptying, abdominal pain,
recurrent nausea, or recurrent vomiting............
With symptoms of chronic intestinal pseudo- 30
obstruction (CIPO) or symptoms of intestinal
motility disorder, including but not limited to,
abdominal pain, bloating, feeling of epigastric
fullness, dyspepsia, nausea and vomiting,
regurgitation, constipation, and diarrhea, managed
by ambulatory care; and requiring prescribed
dietary management or manipulation.................
Intermittent abdominal pain with epigastric fullness 10
associated with bloating; and without evidence of a
structural gastrointestinal disease................
Note: Use this diagnostic code for illnesses
associated with Sec. 3.317(a)(2)(i)(B)(3) of this
chapter, other than those which can be evaluated
under DC 7319.
7357 Post pancreatectomy syndrome:
Following total or partial pancreatectomy, evaluate
under Pancreatitis, chronic (DC 7347), Chronic
complications of upper gastrointestinal surgery (DC
7303), or based on residuals such as malabsorption
(Intestine, small, resection of, DC 7328), diarrhea
(Irritable bowel syndrome, DC 7319, or Crohn's
disease or undifferentiated form of inflammatory
bowel disease, DC 7326), or diabetes (DC 7913),
whichever provides the highest evaluation..........
Minimum............................................. 30
------------------------------------------------------------------------
* * * * *
0
6. Amend appendix A to part 4 by:
0
a. Adding entries in numerical order for Sec. Sec. 4.110, 4.111, and
4.112; and
0
b. Revising and republishing the entry for Sec. 4.114.
The additions and revision read as follows:
[[Page 19750]]
Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------
* * * * * * *
4.110.......................... .............. Removed and reserved
May 19, 2024.
4.111.......................... .............. Removed and reserved
May 19, 2024.
4.112.......................... .............. Revised May 19, 2024.
* * * * * * *
4.114.......................... .............. Introduction paragraph
revised March 10,
1976; introduction
paragraph revised May
19, 2024.
7200 Title, criterion May
19, 2024.
7201 Criterion May 19, 2024.
7202 Evaluation, criterion,
note May 19, 2024.
7203 Evaluation, criterion,
note May 19, 2024.
7204 Title, note May 19,
2024.
7205 Note May 19, 2024.
7206 Added May 19, 2024.
7207 Added May 19, 2024.
7301 Title, Evaluation,
criterion, note May
19, 2024.
7302 Removed April 8, 1959.
7303 Added May 19, 2024.
7304 Evaluation November 1,
1962; title,
evaluation, criterion,
and note May 19, 2024.
7305 Evaluation November 1,
1962; Removed May 19,
2024.
7306 Criterion April 8,
1959; Removed May 19,
2024.
7307 Evaluation May 22,
1964; Criterion May
22, 1964; Note May 22,
1964; title,
evaluation, criterion,
and note May 19, 2024.
7308 Title April 8, 1959;
evaluation April 8,
1959; evaluation and
criterion May 19,
2024.
7309 Evaluation May 19,
2024.
7310 Evaluation May 19,
2024.
7311 Criterion July 2, 2001.
7312 Evaluation March 10,
1976; evaluation July
2, 2001; title,
evaluation, criterion,
and note May 19, 2024.
7313 Evaluation March 10,
1976; removed July 2,
2001.
7314 Title, evaluation, note
May 19, 2024.
7315 Evaluation May 19,
2024.
7316 Removed May 19, 2024.
7317 Note May 19, 2024.
7318 Title, evaluation, and
criterion May 19,
2024.
7319 Title November 1, 1962;
evaluation November 1,
1962; title,
evaluation, criterion,
and note May 19, 2024.
7321 Evaluation July 6,
1950; criterion March
10, 1976; Removed May
19, 2024.
7322 Removed May 19, 2024.
7323 Criterion and note May
19, 2024.
7324 Removed May 19, 2024.
7325 Note November 1, 1962;
note May 19, 2024.
7326 Note November 1, 1962;
title, evaluation,
criterion and note May
19, 2024.
7327 Evaluation November 1,
1962; criterion
November 1, 1962; note
November 1, 1962;
title, evaluation,
criterion, and note
May 19, 2024.
7328 Evaluation November 1,
1962; title,
evaluation, criterion,
and note May 19, 2024.
7329 Evaluation November 1,
1962; evaluation,
criterion, and note
May 19, 2024.
7330 Evaluation November 1,
1962; criterion and
note May 19, 2024.
7331 Criterion March 11,
1969.
7332 Evaluation November 1,
1962; evaluation,
criterion, and note
May 19, 2024.
7333 Evaluation, criterion,
and note May 19, 2024.
7334 Evaluation July 6,
1950; evaluation
November 1, 1962;
evaluation, criterion,
and note May 19, 2024.
7335 Evaluation and
criterion May 19,
2024.
7336 Criterion November 1,
1962; criterion May
19, 2024.
7337 Title, evaluation, and
criterion May 19,
2024.
7338 Title, evaluation,
criterion, and note
May 19, 2024.
7339 Criterion March 10,
1976; removed May 19,
2024.
7340 Removed May 19, 2024.
7341 Removed March 10, 1976.
7343 Criterion March 10,
1976; criterion July
2, 2001.
7344 Criterion July 2, 2001;
note May 19, 2024.
7345 Evaluation August 23,
1948; evaluation
February 17, 1955;
evaluation July 2,
2001; title May 19,
2024; evaluation,
criterion, and note
May 19, 2024.
7346 Evaluation February 1,
1962; title May 19,
2024; evaluation,
criterion, and note
May 19, 2024.
7347 Added September 9,
1975; title May 19,
2024; evaluation,
criterion, and note
May 19, 2024.
7348 Added March 10, 1976;
criterion and note May
19, 2024.
7350 Added May 19, 2024.
7351 Added July 2, 2001;
evaluation, criterion,
and note May 19, 2024.
7352 Added May 19, 2024.
7354 Added July 2, 2001;
evaluation, criterion,
and note May 19, 2024.
[[Page 19751]]
7355 Added May 19, 2024.
7356 Added May 19, 2024.
7357 Added May 19, 2024.
* * * * * * *
------------------------------------------------------------------------
0
7. Amend appendix B to part 4 by revising and republishing the entries
in the table under ``The Digestive System'' to read as follows:
Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------
* * * * * * *
------------------------------------------------------------------------
The Digestive System
------------------------------------------------------------------------
7200................................. Soft tissue injury of the mouth,
other than tongue or lips.
7201................................. Lips, injuries.
7202................................. Tongue, loss of whole or part.
7203................................. Esophagus, stricture.
7204................................. Esophageal motility disorder.
7205................................. Esophagus, diverticulum.
7206................................. Gastroesophageal reflux disease.
7207................................. Barrett's esophagus.
7301................................. Peritoneum, adhesions of, due to
surgery, trauma, or infection.
7303................................. Chronic complications of upper
gastrointestinal surgery.
7304................................. Peptic ulcer disease.
7305................................. [Removed].
7306................................. [Removed].
7307................................. Gastritis, chronic.
7308................................. Postgastrectomy syndromes.
7309................................. Stomach, stenosis.
7310................................. Stomach, injury of, residuals.
7311................................. Liver, injury of, residuals.
7312................................. Cirrhosis of the liver.
7314................................. Chronic biliary tract disease.
7315................................. Cholelithiasis, chronic.
7316................................. [Removed].
7317................................. Gallbladder, injury of.
7318................................. Cholecystectomy (gallbladder
removal), complications of (such
as strictures and biliary
leaks).
7319................................. Irritable bowel syndrome (IBS).
7321................................. [Removed].
7322................................. [Removed].
7323................................. Colitis, ulcerative.
7324................................. [Removed].
7325................................. Enteritis, chronic.
7326................................. Crohn's disease or
undifferentiated form of
inflammatory bowel disease.
7327................................. Diverticulitis and
diverticulosis.
7328................................. Intestine, small, resection of.
7329................................. Intestine, large, resection.
7330................................. Intestinal fistulous diseases,
external.
7331................................. Peritonitis.
7332................................. Rectum and anus, impairment of
sphincter control.
7333................................. Rectum & anus, stricture.
7334................................. Rectum, prolapse.
7335................................. Ano, fistula in, including
anorectal fistula, anorectal
abscess.
7336................................. Hemorrhoids, external or
internal.
7337................................. Pruritus ani (anal itching).
7338................................. Hernia, including femoral,
inguinal, umbilical, ventral,
incisional, and other (but not
including hiatal).
7339................................. [Removed].
7340................................. [Removed].
7342................................. Visceroptosis.
7343................................. Neoplasms, malignant.
7344................................. Benign neoplasms, exclusive of
skin growths.
7345................................. Chronic liver disease without
cirrhosis.
7346................................. Hiatal hernia and paraesophageal
hernia.
7347................................. Pancreatitis, chronic.
[[Page 19752]]
7348................................. Vagotomy with pyloroplasty or
gastroenterostomy.
7350................................. Liver abscess.
7351................................. Liver transplant.
7352................................. Pancreas transplant.
7354................................. Hepatitis C (or non-A, non-B
hepatitis).
7355................................. Celiac disease.
7356................................. Gastrointestinal dysmotility
syndrome.
7357................................. Post pancreatectomy syndrome.
* * * * * * *
------------------------------------------------------------------------
0
8. Amend appendix C to part 4 by:
0
a. Adding in alphabetical order under the entry for ``Abscess'',
entries for ``Anorectal'' and ``Liver'';
0
b. Revising the entry for ``Cholangitis, chronic'';
0
c. Adding in alphabetical order an entry for ``Cholecystectomy
(gallbladder removal), complications of (such as strictures and biliary
leaks)'';
0
d. Adding in alphabetical order under the entry for ``Disease'',
entries for ``Celiac'', ``Crohn's'', ``Gallbladder and biliary tract,
chronic'', and ``Inflammatory bowel'';
0
e. Removing the entry for ``Diverticulitis'' and adding in its place an
entry for ``Diverticulitis and diverticulosis'';
0
f. Adding in alphabetical order under the entry for ``Esophagus'',
entries for ``Barrett's'' and ``Motility disorder'';
0
g. Removing the entry for ``Gastritis, hypertrophic'' and adding in its
place an entry for ``Gastritis, chronic'';
0
h. Adding, in alphabetical order, an entry for ``Gastroesophageal
reflux disease'';
0
i. Revising the entry for ``Hernia'';
0
j. Removing, under the entry for ``Injury'', the entries for ``Gall
bladder'' and ``Mouth'' and adding in their place entries for
``Gallbladder'' and ``Mouth, soft tissue'', respectively;
0
k. Removing the entry for ``Intestine, fistula of'' and adding in its
place an entry for ``Intestine:'' and subentries for ``Fistulous
disease, external'', ``Large, resection of'', and ``Small, resection
of'';
0
l. Removing the entry for ``Irritable colon syndrome'' and adding in
its place an entry for ``Irritable bowel syndrome (IBS)'';
0
m. Removing the entry for ``Pancreatitis'' and adding in its place an
entry for ``Pancreas:'' and subentries for ``Chronic pancreatitis'',
``Post pancreatectomy syndrome'', ``Surgery, complications of'', and
``Transplant'';
0
n. Removing the entry for ``Pruritus ani'' and adding in its place an
entry for ``Pruritus ani (anal itching)'';
0
o. Removing the entry for ``Stomach, stenosis of'' and adding in its
place an entry for ``Stomach:'' and subentries for ``Postgastrectomy
syndrome'', ``Stenosis of'', and ``Surgery, complications of'';
0
p. Adding in alphabetical order under the entry for ``Syndromes'',
entries for ``Gastrointestinal dysmotility'', ``Postgastrectomy'', and
``Post pancreatectomy''; and
0
q. Removing the entry for ``Ulcer'' and subentries ``Duodenal'',
``Gastric'', and ``Marginal'' adding in their place an entry for
``Ulcer, peptic''.
The revisions and additions read as follows:
Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
Diagnostic
code No.
------------------------------------------------------------------------
* * * * * * *
Abscess:
Anorectal........................................... 7335
* * * * * * *
Liver............................................... 7350
* * * * * * *
* * * * * * *
Cholangitis, chronic.................................... 7314
Cholecystectomy (gallbladder removal), complications of 7318
(such as strictures and biliary leaks).................
* * * * * * *
Disease:
* * * * * * *
Celiac.............................................. 7355
* * * * * * *
Crohn's............................................. 7326
Gallbladder and biliary tract, chronic.............. 7314
* * * * * * *
Inflammatory bowel.................................. 7326
[[Page 19753]]
* * * * * * *
* * * * * * *
Diverticulitis and diverticulosis................... 7327
* * * * * * *
Esophagus:
Barrett's........................................... 7207
* * * * * * *
Motility disorder................................... 7204
* * * * * * *
* * * * * * *
Gastritis, chronic...................................... 7307
Gastroesophageal reflux disease......................... 7206
* * * * * * *
Hernia:
Femoral, inguinal, umbilical, ventral, incisional, 7338
and other..........................................
Hiatal and parasophageal............................ 7346
Muscle.............................................. 5326
* * * * * * *
Injury:
* * * * * * *
Gallbladder......................................... 7317
* * * * * * *
Mouth, soft tissue.................................. 7200
* * * * * * *
Intestine:
Fistulous disease, external......................... 7330
Large, resection of................................. 7329
Small, resection of................................. 7328
Irritable bowel syndrome (IBS)...................... 7319
* * * * * * *
Pancreas:
Chronic pancreatitis................................ 7347
Post pancreatectomy syndrome........................ 7357
Surgery, complications of........................... 7303
Transplant.......................................... 7352
* * * * * * *
Pruritus ani (anal itching)......................... 7337
* * * * * * *
Stomach:
Postgastrectomy syndrome............................ 7308
Stenosis of......................................... 7309
Surgery, complications of........................... 7303
* * * * * * *
Syndromes:
* * * * * * *
Gastrointestinal dysmotility........................ 7356
* * * * * * *
Postgastrectomy..................................... 7308
Post pancreatectomy................................. 7357
* * * * * * *
* * * * * * *
Ulcer, peptic....................................... 7304
[[Page 19754]]
* * * * * * *
------------------------------------------------------------------------
[FR Doc. 2024-05138 Filed 3-19-24; 8:45 am]
BILLING CODE 8320-01-P
