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Friday, February 8, 2019

Proposed Changes to the Ratings of Infectious Diseases, Immune Disorders, and Nutritional Deficiencies

On February 5th, 2019, the VA published a new section of proposed VASRD changes, this time to the ratings of Infectious Diseases, Immune Disorders, and Nutritional Deficiencies

The rewrite of the VASRD began in 2014 with the goal to be finished by the end of 2016. While they clearly haven’t met their goal, the VA continues to slowly release proposed and finalized changes. 

So far, finalized changes have been made to the ratings of the Skin, the Female Reproductive System, the Eyes, the Dental and Oral Conditions, the Endocrine System, and Mental Disorders.

Other proposed changes that have not yet been finalized include the Genitourinary System and the Musculoskeletal System.

With each set of proposed changes, the VA allows a period in which comments can be submitted. The VA then takes each comment into consideration and makes any additional changes that are warranted before publishing the final ruling. 

We encourage you to submit any comments you might have on these proposed changes to us either by commenting on this post or by contacting us through our website. All comments must be received by April 8th, 2019. We will then compile all of your comments into a single report and submit it on your behalf to the VA, just as we did for the other sections (see the Female Reproductive System Comments). This is a great opportunity to really make a difference, so please let us know your thoughts. 
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The following are the VA’s proposed changes to the ratings for Infectious Diseases, Immune Disorders, and Nutritional Deficiencies. The changes are fairly extensive, so I’ll walk through each, one at a time.

For each condition, the small, indented parts are the codes as they are right now. Click on the links to be taken to the discussion of that code on our site. After the current code, I’ll discuss the proposed changes and the VA’s justification. 
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-NEW Proposed- General Rating System for Infectious Diseases

A 100% rating is given for all active diseases. Once the infection is eliminated or completely suppressed, the condition must be re-evaluated and rated 0%. Any lasting side effects caused by the infection are then rated separately.  

The VA is proposing to create a General Rating System for Infectious Diseases. This doesn’t have a huge effect on the ratings as currently all infectious diseases are rated 100% while active, then on residual symptoms/conditions. Regardless, creating a central rating system like this will more greatly ensure consistency in applying the ratings to infectious diseases. 

The addition of a 0% rating for an inactive disease also doesn’t have any direct impact on the ratings themselves, but will allow for an easier adjustment to the ratings if the disease relapses.   
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-Current- Code 6300Asiatic cholera is an infection in the small intestine that causes severe diarrhea and vomiting. The 100% rating for this condition continues for 3 months after the active infection. If there are symptoms left over after the 3-month period, then they are rated separately. These symptoms could include papillary necrosis, which is rated under code 7538.

-Proposed- Code 6300:  Vibriosis (cholera and non-cholera) is an infection in the small intestine caused by Vibrio bacteria. It is rated on the General Rating System. Lasting side effects could include renal failure, skin conditions, and musculoskeletal conditions (like muscle damage, arthritis, etc.).  

Currently, this code only covers Asiatic cholera, which is caused by the Vibriobacteria. This bacteria, however, can cause many other types of infections as well. To ensure that those infections are properly recognized and rated, the VA proposes changing this code to include all Vibrioinfections. The other change to this code is to eliminate the 100% rating for the 3 months after the active infection since modern treatments allow full recovery in a fairly short time period. 
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-Current- Code 6301: Visceral leishmaniasis is a disease of parasites in the internal organs that can cause symptoms like weight loss, fever, and anemia. The 100% rating for this condition continues for the first 6 months after treatment for this disease ends. It is then reevaluated, and any remaining symptoms or side effects are rated separately. These symptoms could include liver damage, which is rated under code 7312.

-Proposed - Code 6301: Visceral leishmaniasis is a disease of parasites in the internal organs that can cause symptoms like weight loss, fever, and anemia. It is rated 100% while it is active. The 100% rating for this condition continues for the first 6 months after treatment for this disease is no longer active. It is then reevaluated, and any remaining side effects are rated separately. These side effects could include liver damage and bone marrow diseases.

If the infection recurs, it must be officially confirmed by culture, histopathology, or other lab test. 

The only changes to this code are to include bone marrow diseases in the list of potential residuals and to specify that any recurrence must be properly confirmed by lab test. 
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-Current- Code 6302: Leprosy (or “Hansen’s Disease”) is a bacterial disease that attacks the skin, nerves, and airways. It causes severe skin damage and can lead to many other conditions if left untreated. The 100% rating for this condition continues for the first 6 months after treatment for this disease ends. It is then reevaluated, and any remaining symptoms or side effects are rated separately. These symptoms could include skin damage, codes 7800–7805, or nerve damage. Nerve damage is a bit complicated to rate, and the code depends on which nerves are damaged. Thorough information on rating nerve damage can be found on The Central Nervous System page.


-Proposed - Code 6302: Leprosy (or “Hansen’s Disease”) is a bacterial disease that attacks the skin, nerves, and airways. It causes severe skin damage and can lead to many other conditions if left untreated. The 100% rating for this condition continues for the first 6 months after treatment for this disease ends. It is then re-evaluated, and any remaining side effects are rated separately. These side effectscould include skin damage, nerve damage, or amputation.

The VA proposes to add amputations to the list of possible residuals since leprosy can lead to auto-amputation.  
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-Current- Code 6304: Malaria is a disease of parasites that infect red blood cells and cause severe fevers and other symptoms. For malaria to be properly diagnosed, it must be confirmed by blood smear tests unless it is clear that the veteran was in an area where contamination could be very likely. The 100% rating for this condition continues only while the condition is active. Afterwards, any remaining side effects are rated separately. These symptoms could include liver damage, which is rated under code 7312.

-Proposed - Code 6304: Malaria is a disease of parasites that infect red blood cells and cause severe fevers and other symptoms. It is rated on the General Rating System. For malaria to be properly diagnosed (initially and for any recurrence), it must be confirmed by blood smear tests or lab tests, like antigen detection, immunologic tests, and molecular tests. Side effectscould include liver damage, spleen damage, and central nervous system conditions.

The VA is proposing to require proper tests to diagnose all cases of malaria before they can be rated. They also are adding a few potential symptoms to the list, though these lists are never exhaustive.  
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-Current- Code 6305: Lymphatic filariasis is a disease of parasites that infect the lymphatic system, including the lymph nodes. The 100% rating for this condition continues only while the condition is active. Afterwards, any remaining symptoms or side effects are rated separately. These symptoms could include epididymitis, which is rated under code 7525.

-Proposed - Code 6305: Lymphatic filariasis (“elephantiasis”) is a disease of parasites that infect the lymphatic system, including the lymph nodes. It is rated on the General Rating System. Side effectscould include epididymitis and various lymphatic conditions.

The only proposed change here is to include the name “elephantiasis” that is commonly used to refer to this condition and to include various lymphatic conditions in the list of side effects. 
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-Current- Code 6306: Bartonellosis is a bacterial infection which can cause many other diseases including trench fever, chronic bacteremia, endocarditis, neurological conditions, Carrion’s disease, cat-scratch disease, bacillary angiomatosis, peliosis hepatis, and chronic lymphadenopathy. All of these conditions are rated under this code. The 100% rating for this condition continues for three months after the condition is active. Afterwards, any remaining symptoms or side effects are rated separately. These symptoms could include skin damage, which is rated under codes 7800–7805.

-Proposed- Code 6306: Bartonellosis is a bacterial infection which can cause many other diseases including trench fever, chronic bacteremia, neurological conditions, Carrion’s disease, cat-scratch disease, bacillary angiomatosis, peliosis hepatis, and chronic lymphadenopathy. All of these conditions are rated under this code. 

It is rated on the General Rating System. Side effects could include skin damage and endocarditis.

Again, not a huge change. Removing the three-month rating since it is usually easily treated and including endocarditis as a potential side effect. 
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-Current- Code 6307: Plague (any kind) is a bacterial infection that can attack different parts of the body. It can be treated if caught early. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include gangrene that could lead to amputation. It would then be rated on the amputation of the particular body part. See the Amputations page for a complete list of amputation ratings. In addition to gangrene, this condition could also cause nerve or brain damage. The code depends on the extent of the nerve or brain damage. All nerve and brain conditions are discussed on The Central Nervous System page.

-Proposed- Code 6307: Plague (any kind) is a bacterial infection that can attack different parts of the body. It is rated on the General Rating System.

Treatments for the plague are advanced to the point that residuals or side effects are very rare. They can absolutely be rated if they occur, but the VA feels that they no longer need to be directly discussed. 
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-Current- Code 6308: Relapsing fever is a bacterial infection that causes fevers, chills, aches, and nausea that can last between 2 and 9 days. Every couple of weeks, these symptoms return if not treated with antibiotics. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include liver damage, code 7312, spleen damage, codes 7706-7707, or nerve damage. The code for nerve damage depends on which nerve is affected and the severity of the damage. Thorough information on rating nerve damage can be found on The Central Nervous System page.

-Proposed- Code 6308: Relapsing fever is a bacterial infection that causes fevers, chills, aches, and nausea that can last between 2 and 9 days. Every couple of weeks, these symptoms return if not treated with antibiotics. It is rated on the General Rating System. Side effects could include liver damage, spleen damage, choroidopathy, or nerve damage

The VA’s proposing to add choroidopathy (like iritis, uveitis, etc.) as a potential side effect.
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-Current- Code 6309: Rheumatic fever is a disease that affects the tissues of the body, causing them to swell. It can damage the valves of the heart, which can cause congestive heart failure. Symptoms also include rashes, twitching in the face and arms, and fevers. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include heart damage, code 7020.

-Proposed- Code 6309: Rheumatic fever is a disease that affects the tissues of the body, causing them to swell. It can damage the valves of the heart, which can cause congestive heart failure. Symptoms also include rashes, twitching in the face and arms, and fevers. It is rated on the General Rating System. Side effects could include heart damage, code 7020.

The only proposed change to this code is for it to be rated on the General Rating System. 
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Code 6310 for syphilis remains the same.
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-Current- Code 6311: Miliary tuberculosis is tuberculosis that began in the lungs but then traveled to other parts of the body. This condition would be rated for both pulmonary and nonpulmonary tuberculosis. (Their 100% ratings, however, cannot be combined during the 1-year period after inactivity. Their symptoms or complications, however, can be rated during that period instead of waiting for reevaluation at the 1-year mark).

-Proposed- Code 6311: Miliary tuberculosis is tuberculosis that began in the lungs but then traveled to other parts of the body. This condition is rated 100% while active. Once inactive, the 100% rating continues for one year, and any side effects not covered by this rating (things that would qualify the veteran for additional benefits, like SMC) can be rated as well. At the end of the 1-year period, the condition is re-evaluated, and any side effects, like skin conditions, respiratory conditions, eye conditions, digestive conditions, etc., can be rated separately. 

If the infection recurs, it must be officially confirmed by culture, histopathology, or other lab test. 

The ratings for this code haven’t actually changed at all, but the VA is hoping to create a clearer rating system by simplifying the language of this code instead of referring to other codes. 
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-Proposed NEW CODE- Code 6312:  Non-tuberculosis mycobacterial infection (“NTM”) is a lung infection, that isn’t tuberculosis, which occurs when bacteria is inhaled. This can cover a wide-range of infections caused by different types of inhaled bacteria. This condition is rated 100% while active. Once inactive, the condition is re-evaluated, and any side effects, like skin conditions, respiratory conditions, eye conditions, digestive conditions, etc., can be rated separately. 

If the infection recurs, it must be officially confirmed by culture, histopathology, or other lab test. 

The VA proposes to add this new code to cover all inhaled bacterial infections. Currently, tuberculosis is the only code similar enough to cover these infections, but tuberculosis presents differently and has more severe long-term implications than many of these other infections. As such, this code would enable a clearly distinct rating option for these conditions. 
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Code 6313 for Avitaminosis, code 6314 for Beriberi, and code 6315 for Pellagra will remain the same.
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-Current- Code 6316: Brucellosis is a bacterial infection that causes fevers, headaches, depression, and weakness. The symptoms can come and go throughout the rest of your life if the disease is not properly treated with antibiotics. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include liver damage, code 7312, or meningitis, code 8019.

-Proposed- Code 6316: Brucellosis is a bacterial infection that causes fevers, headaches, depression, and weakness. Diagnosis and any recurrence must be confirmed by culture and/or serologic testing. It is rated on the General Rating System. Side effects could include liver damage, meningitis, and spleen damage.

The VA proposes to require the appropriate tests to diagnose the condition in order to ensure both proper rating and proper treatment.  
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-Current- Code 6317: Scrub typhus is an infection caused by parasites that can be treated with antibiotics, although many strains are not responsive to treatments. The 100% rating for this condition continues while the condition is active and for the first 3 months following. After that, any remaining side effects or symptoms are rated separately. These symptoms could include skin damage, codes 7800–7805, and spleen damage, codes 7706-7707.

-Proposed- Code 6317:  Rickettsial infections (including scrub typhuserlichiosis, and anaplasmosisare rated under this codeThese diseases are all commonly passed from ticks, fleas, or other parasites. It is rated on the General Rating System. Side effects could include bone marrow conditions, skin conditions, central nervous conditions, and spleen damage.

The VA proposes to broaden the name of the code to include all conditions caused by rickettsial infections, not just scrub typhus. These conditions are already rated analogously under this code, but this change will make it easier to rate them. They are also proposing to remove the 3-month rating after the active infection since these infections are easily controlled by modern medicines. 
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-Current- Code 6318: Melioidosis is a bacterial infection that causes pain, coughing, pneumonia and skin infections. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include arthritis, code 5003, lung tissue damage, code 6825, or meningitis, code 8019.

-Proposed- Code 6318: Melioidosis is a bacterial infection that causes pain, coughing, pneumonia, and skin infections. Diagnosis and any recurrence must be confirmed by culture or appropriate lab testing. It is rated on the General Rating System. Side effects could include arthritis, meningitis, and lung lesions.

The VA proposes to require the appropriate tests to diagnose the condition in order to ensure both proper rating and proper treatment.  
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-Current- Code 6319: Lyme disease is a bacterial disease common in the US and spread by ticks. Symptoms include fever, skin rash, fatigue, and depression and can affect the joints, heart and nerves if it is not treated properly. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include arthritis, codes 5002-5003, heart damage, code 7020, chronic fatigue, code 6354, and nerve damage.

-Proposed- Code 6319: Lyme disease is a bacterial disease common in the US and spread by ticks. Symptoms include fever, skin rash, fatigue, and depression and can affect the joints, heart, and nerves if it is not treated properly. It is rated on the General Rating System. Side effects could include arthritis, Bell’s palsy, nerve damage, eye conditions, and mental dysfunction.

The only proposed change is to adjust the side effects list to include the most common side effects for this condition. 
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Code 6320 for other parasitic diseases will remain the same.
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-NEW Proposed Code- Code 6325: Hyperinfection syndrome (“disseminated strongyloidiasis”) is a parasitic disease caused by roundworms. Symptoms include severe infections, diarrhea, skin rash, and weight loss. It is rated 100% while active. Once it is inactive, it is re-evaluated and rated on any remaining side effects. 

The VA proposes adding a new code for hyperinfection syndrome, a condition that presents unique symptoms and causes an incredibly severe infection with a high mortality rate and vast, significant side effects. 
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-NEW Proposed Code- Code 6326: Shistosomiasis (“Katayama syndrome”) is an extremely common parasitic disease outside of the US. Symptoms include skin rash, fever, and headaches. This condition is usually mild in most people, but some can have negative reactions to the parasite eggs that can cause long-term side effects. Since the active infection itself is mild, it is rated 0%. However, in cases that cause side effects, like liver damage, digestive conditions, genitourinary conditions, female reproductive conditions, or central nervous conditions, they can be rated separately. 

The VA proposes adding a new code for shistosomiasis, a unique condition that is usually mild but can have significant disabling effects in some veterans. This code would allow those veterans affected to be properly rated. 
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-NEW Proposed Code- Code 6329: Hemorrhagic fevers (including dengue feveryellow fever, etc.) are fevers caused by a viral infection. It is rated on the General Rating System. Side effects could include liver damage, kidney damage, and central nervous conditions.  

The VA proposes adding this new code to avoid having to rate these fevers analogously.  
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-NEW Proposed Code- Code 6330: Campylobacter jejuni is the most common type of food poisoning. Symptoms include diarrhea, nausea, and fever. It is rated on the General Rating System. Side effects could include uveitis, Guillain-Barre syndrome, and reactive arthritis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6331: Coxiella burnetii infection (“Q fever”) is a bacterial infection spread by animals which causes flu-like symptoms. It is rated on the General Rating System. Side effects could include chronic hepatitis, chronic fatigue syndrome, and osteomyelitis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6333: Salmonella infections (non-typhoid) is the most common type of food poisoning. Symptoms include diarrhea, nausea, and fever. It is rated on the General Rating System. Side effects could include reactive arthritis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6334: Shigella infections (including dysenteryare the most common cause of diarrhea. It is rated on the General Rating System. Side effects could include hemolytic-uremic syndrome and reactive arthritis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6335: West Nile virus infections are spread by mosquitoes. Symptoms include headache, vomiting, and fever. It is rated on the General Rating System. 

The VA proposes adding this new code to avoid having to rate it analogously.  
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Code 6350 for lupus erythematosus will remain the same.
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-Current- Code 6351: HIV (human immunodeficiency virus) is a virus mostly spread by sexual contact with an infected person, although it can also be spread from mother to child or by contact with infected blood. The virus attacks “T4” cells that support the immune system of the body, thus causing the body to be very vulnerable to infections, other diseases (“secondary diseases”), and cancers. The HIV virus can cause the disease AIDS (acquired immunodeficiency syndrome). It takes many years for an HIV infection to develop into AIDS. The presence of AIDS is confirmed if the T4 cell count is less than 200.

If a higher rating can be received by rating a secondary disease or infection than can be received by rating HIV or AIDS, then it can be rated under that secondary condition. A rating for both, however, is not allowed—only a rating for HIV or a rating for ONE of the secondary conditions, whichever can provide the higher rating. If it is rated on one of the secondary conditions, then the final code will look like this: 6351-4901. The first four-digit code defines the condition as HIV, and the second four-digit code tells how the condition is rated.

The ratings:

If there is an active AIDS disease with either regularly occurring infections/diseases or infections/diseases in numerous areas of the body, it is rated 100%. A 100% rating is also given for HIV if there is a secondary disease that is present the majority of the time and causes continual weight loss.

If there is a secondary disease, infection, or neoplasm as a result of AIDS, then the minimum rating is 60%. This rating is also given if there are significant symptoms throughout the body that cannot be controlled, diarrhea, and weight loss.

If the HIV is being treated by “approved” medication (medications that are prescribed for research by a qualified medical institution), but there are still regularly occurring symptoms throughout the body and intermittent diarrhea, then it is rated 30%. This rating is also the minimum rating given if the T4 cell count is less than 200, there is hairy cell leukoplakis, or oral candidiasis.

If the HIV is being treated by “approved” medication, there are at least definite symptoms present, and the T4 cell count is between 200 and 500, then it is rated 10%. If there are clear signs of depression or memory loss that interfere with the ability to work, a rating of 10% may also be given.

If there are no symptoms that affect the ability of the individual to function, then it is rated 0%, even if there is a decreased T4 cell count, disease in the lymph nodes, or diagnosed AIDS.

-Proposed- Code 6351: HIV (human immunodeficiency virus) is a virus mostly spread by sexual contact with an infected person, although it can also be spread from mother to child or by contact with infected blood. The virus attacks “T4” cells that support the immune system of the body, thus causing the body to be very vulnerable to infections, other diseases (“secondary diseases”), and cancers. 

The HIV virus can cause the disease AIDS (acquired immunodeficiency syndrome). It takes many years for an HIV infection to develop into AIDS. The diagnosis of AIDS is confirmed if the T4 cell count is less than 200 or if there is the presence of one of the following opportunistic infections in addition to HIV.

Opportunistic Infections
- Candidiasis of the bronchi, trachea, esophagus, or lungs
- Invasive cervical cancer
- Coccidioidomycosis
- Cryptococcosis
- Cryptosporidiosis
- Cytomegalovirus (including CMV retinitis)
- Encephalopathy
- Herpes simplex-chronic ulcers (must be present more than 1 month)
- Bronchitis
- Pneumonia
- Esophagitis
- Histoplasmosis
- Chronic intestinal isosporiasis
- Kaposi’s sarcoma
- Lymphoma
- Mycobacterium avium complex
- Tuberculosis
- Pneumocystis jirovecii pneumonia
- Recurrent pneumonia
- Progressive multifocal leukoencephalopathy
- Recurrent Salmonella septicemia
- Toxoplasmosis of the brain
- Wasting syndrome

Secondary diseases or infections, like diagnosed mental disorders, opportunistic infections, neoplasms, and central nervous system conditions, may be rated separately in addition to a rating under this code as long as symptoms do not overlap (Pyramiding Principle). For example, chronic bronchitis can be rated in addition to a rating under this code as the ratings cover different symptoms. However, a rating for Major Depressive Disorder cannot be given in addition for a 10% rating based on depression under this code as they both are rating the symptom of depression. In these cases, only one rating can be given. 

The ratings:

If there is AIDS and an opportunistic infection or a disease that affects numerous areas of the body, it is rated 100%. A 100% rating is also given for HIV if there is a secondary disease that is present the majority of the time and causes continual weight loss.

If there is an opportunistic infection or neoplasm, then the minimum rating is 60%. This rating is also given if there are diarrhea, weight loss, and other significant symptoms throughout the body that cannot be controlled.

If the HIV is being treated by “approved” medication (medications and treatment regimens that are prescribed for research by a qualified medical institution), but there are still regularly occurring symptoms throughout the body and intermittent diarrhea, then it is rated 30%. This rating is also the minimum rating given if the T4 cell count is less than 200.

If the HIV is being treated by “approved” medication, there are definite symptoms present, and the T4 cell count is between 200 and 500, then it is rated 10%. If there are clear signs of depression or memory loss that interfere with the ability to work, a rating of 10% is also given.

If there are no symptoms that affect the ability of the individual to function, then it is rated 0%, even if there is a decreased T4 cell count and lymph node disease.

The VA is proposing a number of changes to this code to better rate HIV based on current medical understandings and treatments. The VA proposes adding a list of opportunistic infections to help diagnose the presence of AIDS and allow for more clarity when rating secondary conditions. They are further clarifying that secondary conditions can be rated in addition to a rating under this code as long as there is no pyramiding. 
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-Current- Code 6354: Chronic fatigue syndrome is a condition where there is a long-term severe loss of energy. Many different conditions can produce significant fatigue, so a diagnosis of chronic fatigue syndrome can only be made after proper testing for all other possible conditions is done. The fatigue also has to be severe enough to limit the ability to perform daily activities by half for at least 6 months. Finally, there must be at least 6 or more of the following symptoms present: fever, tender lymph nodes, muscle aches or weakness, sore throat, debilitating fatigue lasting 24 hours or more after exercise, headaches unique to the fatigue (different than headaches before the fatigue began), joint aches, and cognitive problems (bad concentration, forgetfulness, confusion, etc.). 

Note: If the condition requires bed rest prescribed by the physician, then it is considered “incapacitating” during the period of bed rest.

If the symptoms are constant or so severe that it is impossible to perform daily activities, it is rated 100%.

If the symptoms do not completely limit activity, but your activity level is limited to at least half of what it was before the fatigue, or if the symptoms are not constant but there are periods of incapacitation that add up to at least 6 weeks within the past year, then it is rated 60%.

If the symptoms are fairly constant but you can still perform 50 to 75% of the normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 4 and 6 weeks within the past year, then it is rated 40%.

If the symptoms are fairly constant but you can perform 75% or more of your normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 2 and 4 weeks within the past year, then it is rated 20%.

If the symptoms are not constant but there are periods of incapacitation that add up to between 1 and 2 weeks within the past year, or if the symptoms are controlled by constant medication, then it is rated 10%.

-Proposed- Code 6354: Systemic exertion intolerance disease (“chronic fatigue syndrome (CFS)” or “myalgic encephalomyelitis (ME)”) is a condition where there is a long-term severe loss of energy. Many different conditions can produce significant fatigue, so a diagnosis of chronic fatigue syndrome must meet the following criteria:

1. Chronic fatigue severe enough to limit the ability to perform daily activities and work.
2. The presence of at least four of the following:
- debilitating fatigue lasting 24 hours or more after exercise
- unrefreshing sleep
- significant loss of concentration and short-term memory
- muscle pain
- joint pain (without swelling or redness)
- headaches different than headaches previously known
- tender lymph nodes
- frequent, recurring soar throat
3. These symptoms must have been present (or recurred regularly) for at least six months, are not caused by other conditions or by ongoing exertion, and did not first appear before the fatigue.

CFS cannot be diagnosed if:
- There is a current condition (or treatment) that is known to cause chronic fatigue, like sleep apnea, hyperthyroidism, narcolepsy, or numerous medications.
-Illnesses, like some cancers, hepatitis B or C, etc., that could cause chronic fatigue have been diagnosed but not fully resolved.
- Major depressive disorder with psychotic or melancholic features, bipolar affective disorders, anorexia nervosa, bulimia nervosa, schizophrenia, any delusional disorder, or dementia, have ever been diagnosed. 
- There is or has been alcohol or other substance abuse occurring within two years before or any time after the onset of fatigue.
- There is current severe obesity (BMI >45). 
- There is clinical testing or examination resulting in suspicion of one of the above conditions. In these cases, the condition must be diagnosed and treated before a diagnosis of CFS can be revisited.  

The Ratings:

Note: “Periods of incapacitation” only exist if a physician prescribes periods of bed rest and treatment. 

If the symptoms are constant or so severe that it is impossible to perform daily activities, it is rated 100%.

If the symptoms do not completely limit activity, but your activity level is limited to at least half of what it was before the fatigue, or if the symptoms are not constant but there are periods of incapacitation that add up to at least 6 weeks within the past year, then it is rated 60%.

If the symptoms are fairly constant but you can still perform 50 to 75% of the normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 4 and 6 weeks within the past year, then it is rated 40%.

If the symptoms are fairly constant but you can perform 75% or more of your normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 2 and 4 weeks within the past year, then it is rated 20%.

If the symptoms are not constant but there are periods of incapacitation that add up to between 1 and 2 weeks within the past year, or if the symptoms are controlled by constant medication, then it is rated 10%.

The VA proposes to change the name of this condition to ensure inclusion of any condition that causes severe fatigue with exertion. They also propose to update the diagnostic criteria to the current medical norms and to specify when a diagnosis cannot be made. The ratings themselves will not change. 

Monday, November 5, 2018

Official Changes to the Ratings of the Hematologic and Lymphatic Systems

Last week, the VA published their final changes to the ratings of the Hematologic and Lymphatic Systems. Of the nine sets of changes that have been proposed so far as part of the VA’s complete rewrite of the VASRD, this is the seventh to be made official and final. 

The other finalized changes were the new Skin changes made in August, the Female Reproductive System and Eye changes made in May, the changes for Dental and Oral Conditions and the Endocrine System made last fall, and the Mental Disorder changes made in 2014. 

Other proposed changes include the Genitourinary System and the Musculoskeletal System

The following changes will go into effect December 9th, 2018, and we’ll officially update all the information on our website at that time. These new ratings will automatically apply to any new claims for Hematologic and Lymphatic conditions submitted on or after December 9th.

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The following are the VA’s final changes to the ratings for the Hematologic and Lymphatic Systems. The changes are fairly extensive, so I’ll walk through each one individually.

For each condition, the small, indented part is the code as it is right now. Click on the code numbers to be taken to the discussion of that code on our site. After the current code, I’ll discuss the upcoming changes. 

The first change is to update the title of this section from “Hemic and Lymphatic Systems” to “Hematologic and Lymphatic Systems.” Basically, the term “hemic” is a very general label for conditions of the blood and is not used in modern medical terminology much anymore. Instead, “hematologic” is the preferred term for conditions of the blood and the organs directly affecting the blood. 

Now on to the codes.
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Code 7700Anemia that is caused by low levels of iron or B12 in the body is rated under this code. This condition is rated based on the amount of hemoglobin in the blood and symptoms directly related to it. If the anemia causes other complications, like dementia or neuropathy, that are not rated under this code, then those conditions can be rated separately.

The normal hemoglobin level for an adult female is 12 to 16 grams per 100 milliliters of blood (g/dL). For an adult male it is 13.5 – 17.5 g/dL. If the hemoglobin level in the blood is 5 g/dL or less and causes symptoms like difficulty breathing or congestive heart failure, then it is rated 100%. If the hemoglobin level is 7 g/dL or less and causes symptoms like difficulty breathing, an enlarged heart, high blood pressure, or fainting (at least 3 times in the last 6 months), then it is rated 70%. If the hemoglobin level is 8 g/dL or less and causes symptoms like weakness, headaches, fatigue, lightheadedness, or shortness of breath, then it is rated 30%. If the hemoglobin level is 10 g/dL or less and causes symptoms like weakness, fatigue or headaches, then it is rated 10%. If the hemoglobin level is 10 g/dL or less but does not cause any symptoms, then it is rated 0%.

It is important to note that these ratings are based on the hemoglobin level andthe symptoms. After the hemoglobin level for each rating, it says “or less,” meaning that if the condition has an enlarged heart (rated 70%) and the hemoglobin level is 5gm/100ml (rated 100%), then the rating would only be 70% since the hemoglobin level for 70% states 7gm/100ml or less. Regardless of how low the hemoglobin level is, the rating can only go up if the symptoms support it. On the contrary, if the hemoglobin level is higher than the requirement for a particular rating, then it cannot receive a lower rating. For example, if the hemoglobin level is 8gm/100ml (rated 30%) and there is an enlarged heart (rated 70%), the rating would only be 30% since the hemoglobin level is too high for the 70% rating. Finally, if there is a significant heart condition, but only mild anemia, then the condition is only rated on the heart condition under a heart code.

Okay, a lot is happening with anemia. Currently, there are three codes for anemia: this one, code 7714 for sickle cell anemia, and code 7716 for aplastic anemia. Codes 7714 and 7716 will still remain, but the VA is removing this code (7700) and adding four new codes in its place. 

Before discussing the new codes, I want to explain the VA’s reasoning behind these changes. Basically, the majority of cases of anemia are either hereditary or caused by another condition, like hypothyroidism. If the anemia is caused by another condition, then only that other condition should be rated. The anemia is just considered a symptom of that condition, and thus is covered under a rating for that condition. 

The only time anemia should be given its own rating is when it is not directly caused by another ratable condition, or is caused by one of the circumstances addressed by the new codes. The VA is adding these four new codes for anemia in order to better break down and classify the type and severity of the ratable anemia. Each code covers a different type of chronic anemia (anemia that has a gradual onset and lasts over a long period of time), as opposed to acute anemia (anemia directly caused by a traumatic or extreme event, like internal bleeding). Acute anemia should be rated under the condition that caused it. 

-NEW CODE- Code 7720Iron deficiency anemia is a type of anemia caused by low levels of iron in the blood. If the low levels of iron are caused by blood loss, then it is not rated under this code, but under the condition causing the blood loss. 

If the anemia requires iron infusions directly into the veins 4 or more times each year, then it is rated 30%. If it requires iron infusions directly into the veins 1-3 times each year, or if you must continuously take oral iron supplements, it is rated 10%. If it doesn’t cause any symptoms or can be easily controlled by diet, then it is rated 0%. 

This one is pretty straightforward. On to the next. 

-NEW CODE- Code 7721Folic acid deficiency anemia is caused by low levels of folic acid in the blood. If it requires you to continuously take high doses of folic acid supplements, it is rated 10%. If it doesn’t cause any symptoms or can be easily controlled by diet, then it is rated 0%. 

Folic acid deficiency is very rare these days, but when it does occur, it is very easily treated by supplements and diet. Again, pretty straightforward. 

-NEW CODE- Code 7722Vitamin B12 deficiency anemia (including pernicious anemia) is any type of anemia caused by low levels of vitamin B12 in the blood.  This type of anemia is difficult to detect early because the liver stores a lengthy supply of B12, so symptoms do not usually develop until after this supply is depleted. 

If the anemia is severe enough upon diagnosis that it requires a blood transfusion, then it is rated 100% while being treated and for the first 6 months following discharge from the hospital. A 100% rating is also given if the anemia causes nervous system conditions (like myelitisandrequires injections or IV-administered B12. This 100% rating also continues for the first 6 months following the last B12 treatment. In both cases, after the 6-month mark, the VA will re-evaluate the condition. It will then be given a 10% rating under this code, and any additional symptoms, like myelitis, will be rated separately. 

If the condition is not severe enough to warrant a 100% rating, but does require continuous treatment with B12, either by mouth, injection, or nasal spray, it is rated 10%. 

B12 is an important factor in the creation of new red blood cells, and so any deficiency of B12 in the body will directly affect the level of red blood cells, thus leading to anemia. Any type of B12 deficiency will be rated under this code, regardless of the cause of the deficiency. 

-NEW CODE- Code 7723Acquired hemolytic anemia is caused by the abnormal breakdown of red blood cells. “Acquired” means that the anemia is the direct result of a factor like medications, injury, toxic chemicals, etc. 

If it requires a bone marrow transplant, continuous IV treatment, or continuous immunosuppressive therapy (prednisone, etc.), then it is rated 100%. For bone marrow transplants, this 100% rating will continue for the first 6 months following discharge from the hospital. The VA will then re-evaluate the condition and rate it based on any remaining symptoms or treatment needs. 

If it requires immunosuppressive medication 4 or more times each year, it is rated 60%. If it requires immunosuppressive medication 2 to 3 times each year, it is rated 30%. If it requires immunosuppressive medication at least once each year, it is rated 10%. If it does not cause any symptoms, it is rated 0%. 

If the anemia is caused by a complete or partial removal of the spleen, then the spleen is rated separately under code 7706 in addition to a rating under this code.

It’s important to note that only acquired hemolytic anemia can be rated under this code. “Acquired” means that it was not caused naturally or by an underlying condition. If it was caused by an underlying condition, then just that underlying condition would be rated. In this case, “acquired” means that another, separate force caused the anemia. This outside force could include things like chemicals, medications used to treat other conditions (this would not be considered an underlying condition since it was the medication, not the condition itself, that caused the anemia), injuries or procedures (for example, prosthetic heart valves could cause damage to the heart that could lead to anemia), etc. 
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Code 7702Agranulocytosis (also known as granulopenia and agranulosis) is a condition where the bone marrow does not produce enough white blood cells. This significantly decreases the body’s immune system and makes the body very vulnerable to infection and disease. If the condition requires a bone marrow transplant, it is rated 100%. This 100% rating continues for 6 months following the transplant. The condition will then be reevaluated and re-rated.

Whether or not a transplant is performed, if the condition requires a transfusion of platelets or red blood cells at least once every 6 weeks, or if infections occur at least once every 6 weeks, it is rated 100%. If a transfusion or an infection occurs at least once every 3 months, then it is rated 60%. If a transfusion or an infection occurs at least once a year, then it is rated 30%. If the condition at least requires continuous medication, then it is rated 10%.

-Final- Code 7702Agranulocytosis (also known as granulopenia and agranulosis) is a condition where the bone marrow does not produce enough white blood cells. This significantly decreases the body’s immune system and makes the body very vulnerable to infection and disease. 

A few important things to know before getting into the ratings: Neutrophils are a type of white blood cell that are essential to the immune system. There are two main different types of treatment that can be used to maintain an acceptable level of neutrophils in the blood. In medical reports, this will be noted as the ANC (absolute neutrophil count), and will include a volume count in microliters (µl), for example, ANC = 750/µl. 

One type of treatment used to keep the ANC up is myeloid growth factors. These are agents that help produce blood cells. The most common myeloid growth factors are granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF). The second most common type of treatment used to boost the ANC is immunosuppressive therapy—basically drugs, like cyclosporine, that suppress the immune system. 

Now the ratings:

If the condition requires a bone marrow transplant, it is rated 100%. This 100% rating continues for 6 months following the transplant. The condition will then be reevaluated and re-rated based on any remaining symptoms. 

Whether or not a transplant is performed, if infections occur at least once every 6 weeks each year on average, it is rated 100%. 

If continuous immunosuppressive therapy or intermittent myeloid growth factors are needed to keep the ANC between 500/µl and 1,000/µl, or if an infection occurs at least once every 3 months each year on average, then it is rated 60%. 

If intermittent myeloid growth factors are needed to keep the ANC above 1,000/µl, or if an infection occurs at least once a year on average, then it is rated 30%. 

If intermittent myeloid growth factors are needed to keep the ANC at 1,500/µl or above, or if the condition at least requires continuous medication, like antibiotics, then it is rated 10%.

For a while, transfusions were the popular treatment option for agranulocytosis, but they have always been somewhat controversial because of the numerous complications that could arise from them. Today, transfusions are only really used in particularly severe or unique cases. Instead, other forms of treatment have been developed that better help control the symptoms while decreasing the amount and severity of side effects. The VA’s changes better reflect modern treatment practices and allow for the proper rating of agranulocytosis in the absence of transfusions. 
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Code 7703Leukemia is a cancer of the blood or bone marrow that causes the over-production of immature white blood cells. There are many different kinds of leukemia, but all are rated the same. If it is active and undergoing treatment, then it is rated 100%. This 100% rating continues for 6 months after the last treatment. Then the condition will be reevaluated and re-rated. If the leukemia is not active or being treated, then it is rated as anemia or aplastic anemia, whichever gives the higher rating. The final code would look like this: 7703-7700. The first four-digit code defines the condition as leukemia, and the second four-digit code says that it is rated as anemia.

-Final- Code 7703: All leukemia except myelogenous leukemia (see new code 7719) is rated under this code. Leukemia is a cancer of the blood or bone marrow that causes the over-production of immature white blood cells. If it is active and undergoing treatment, then it is rated 100%. This 100% rating continues for 6 months after the last treatment. Then the condition will be reevaluated and re-rated based on any lasting symptoms or other conditions caused by the leukemia or the treatment. 

If the leukemia is chronic lymphocytic leukemia or monoclonal B-cell lymphocytosis, it is rated as all other leukemias unless it is in the first stage (Rai Stage 0) and there are no symptoms. Even when active, chronic lymphocytic leukemia in Rai Stage 0 does not cause any symptoms and so is rated 0%. 

A few changes are happening to the ratings for leukemia. First, the VA decided to separate out chronic myelogenous leukemia and give it its own code, 7719, since it provides some unique problems. I’ll discuss the new code 7719 below. 

Since leukemia can cause a lot of problems throughout the body, not just anemia, the VA is also getting rid of the requirement to rate inactive leukemia as anemia. Instead, any symptoms or conditions, whether anemia or no, can be rated separately under these changes. 

Finally, chronic lymphocytic leukemia in its early stages does not cause any symptoms and thus doesn’t cause a disability. It is only after it progresses to more severe stages that a true disability appears. If detected early and properly treated, this leukemia can stay asymptomatic for many years. Thus, until it develops to a point where symptoms are manifest, the VA will only rate it 0%. 
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Code 7704Polycythemia vera is the opposite of anemia. Instead of having too few red blood cells, the bone marrow produces too many red blood cells. This can cause shortness of breath, bleeding, dizziness and many serious symptoms. If this condition causes a serious side effect like high blood pressure, gout, a stroke or a blood clot, then those conditions are rated separately. They must be serious enough to cause a significant decrease in the ability to function in order to qualify for a rating. For example, slightly high blood pressure that does not limit the amount of activity a person can do is not enough for high blood pressure to be rated separately.

Polycythemia vera is not curable but can be treated. If it requires treatment of myelosuppressants then it is rated 100%. This 100% rating continues for 3 months following the last myelosuppressant treatment. The condition is then reevaluated and re-rated.

Whether or not myelosuppressants were used, if the condition is severe enough that a phlebotomy has to be routinely performed, then it is rated 40%. If the condition is stable whether or not medication is being taken, then it is rated 10%.

-Final- Code 7704Polycythemia vera is the opposite of anemia. Instead of having too few red blood cells, the bone marrow produces too many red blood cells. This can cause shortness of breath, bleeding, dizziness, and many other serious symptoms. If this condition causes a serious side effect like high blood pressure, gout, a stroke or a blood clot, then those conditions are rated separately. They must be serious enough to cause a significant decrease in the ability to function in order to qualify for a rating. For example, slightly high blood pressure that does not limit the amount of activity a person can do is not enough for high blood pressure to be rated separately.

Polycythemia vera is not curable but can be treated.

If it requires a peripheral blood or bone marrow stem-cell transplant, or treatment with chemotherapy (including myelosuppressants), then it is rated 100%. This 100% rating continues for 6 months following the last treatment or discharge from the hospital. The condition is then reevaluated and re-rated.

In order to control the red blood cell count, if it requires a phlebotomy to be performed 6 or more times each year or if it requires molecularly-targeted therapy, then it is rated 60%. 

If it requires a phlebotomy to be performed 4 or 5 times each year, or if it requires continuous therapy (with biologic or myelosuppresive agents, like interferon) to keep the platelet count under 200,000 or the white blood cell count under 12,000, then it is rated 30%. 

If it requires a phlebotomy 3 or less times each year, or if it requires intermittent biologic therapy (like interferon) in order to maintain appropriate levels, then it is rated 10%.

If the condition turns into leukemia, then it is rated as leukemia under code 7703. 

There are many more standard types of treatments for Polycythemia vera now, so the VA’s changes are meant to better reflect the severity of the condition based on the variety of treatments currently used. 
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Code 7705Thrombocytopenia is a condition where the platelet count in the blood is low. The normal amount of platelets in a microliter of blood is between 150,000 to 450,000. If the platelet count is less than 20,000 and there is bleeding that requires medication and transfusions, then it is rated 100%. If the count is between 20,000 and 70,000 but there is no bleeding and it does not require treatment, then it is rated 70%. If the platelet count is stable and between 70,000 and 100,000 and there is no bleeding, then it is rated 30%. A stable count of 100,000 or more with no bleeding is rated 0%.

-Final- Code 7705Thrombocytopenia is a condition where the platelet count in the blood is low. The normal amount of platelets in a microliter of blood is between 150,000 to 450,000. 

If the platelet count remains at 30,000 or less despite treatment, it is rated 100%. A 100% rating is also given if the condition is chronic refractory thrombocytopenia (a specific type of thrombocytopenia) and it requires chemotherapy. This 100% rating continues for 6 months following the last chemotherapy treatment and is then reevaluated and re-rated based on any remaining symptoms. 

A 70% rating is given if the patient had been hospitalized at least once in the past for severe bleeding that was treated with immune globulin, corticosteroids, and platelet transfusions, and the condition currently requires immunosuppressive therapy or the platelet count is between 30,000 and 50,000. 

A 30% rating is given if the platelet count is between 30,000 and 50,000, and there is mild bleeding that requires either oral corticosteroids or immune globulin injections.

A 10% rating is given if the platelet count is between 30,000 and 50,000, but no treatment is required. 

A 0% rating is given if the platelet count is above 50,000, or if the immune thrombocytopenia is in remission. 

If a splenectomy is performed, it is rated separately under code 7706. 

The changes to the ratings for thrombocytopenia are mostly based on the need to better reflect the true disability resulting from this condition and to acknowledge the more modern treatment methods. 
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Codes 7706 and 7707 for conditions of the spleen and splenectomies are remaining exactly the same. 
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Code 7709Hodgkin’s disease is a cancer of the white blood cells (lymphoma) that spreads across the lymph nodes. Hodgkin’s disease is “staged” based on the severity of the cancer. The military will usually place the individual with a lower stage cancer on TDRL and may place him back on active duty after treatment. An individual with a more severe cancer will usually be medically retired.

If the cancer is active or undergoing treatment, then it is rated 100%. This rating continues for 6 months following the last treatment. The condition is then reevaluated and re-rated based on the ongoing symptoms.

The only change to this code is to change the name from “Hodgkin’s disease” to “Hodgkin’s lymphoma,” the name more widely used now. Everything else is exactly the same. 
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No changes are being made to code 7710 for tuberculous adenitis.
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-NEW CODE- Code 7712Multiple myeloma is a type of cancer that creates abnormal plasma cells, a type of white blood cell. These abnormal cells can build up and form tumors, most commonly in the bones but possibly affecting the organs as well, thus causing numerous different symptoms. While multiple myeloma is incurable, it is treatable.

In order for the VA to rate any case of myeloma under this code, it must be officially diagnosed using currently accepted medical standards.  

Smoldering myeloma is the benign precursor to multiple myeloma and is normally symptom-free. It is thus given a 0% rating. The majority of cases of smoldering myeloma do develop into multiple myeloma, and thus should be carefully monitored. As soon as it can be officially diagnosed as multiple myeloma, its rating can be increased. All cases of monoclonal gammopathy of undetermined significance (MGUS) are treated the same. 

Active, diagnosed multiple myeloma with obvious symptoms is rated 100%. This 100% rating continues for 5 years after diagnosis. The condition is then reevaluated by the VA and re-rated as needed. 

There is currently not a code that sufficiently covers and rates multiple myeloma. The addition of this code will allow for more appropriate and precise ratings for this condition. 
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Code 7714Sickle cell anemia is a kind of anemia where the red blood cells that carry the oxygen become shaped like a sickle (or a boomerang). Because of this, they are not able to carry as much oxygen to the body, and they sometimes get stuck in small blood vessels, blocking the blood flow to the tissues. A diagnosis of this condition alone is not enough to get a rating. There must be proof of significant symptoms that limit your ability to function in some way. This condition is genetic, and so it technically did exist prior to service (EPTS), and may not be ratable in some cases.

If there are regular severe painful episodes, blood clots, and other symptoms that all cause the condition to be severe enough that even light manual labor cannot be performed, then it is rated 100%. If there are severe painful episodes multiple times a year with symptoms that restrict activity to just light manual labor, then it is rated 60%. If there have been episodes of severe active destruction of red blood cells and these episodes cause symptoms that continue after the episode is over, then it is rated 30%. If the condition has been properly diagnosed and it affects some organs, but there are no symptoms, then it is rated 10%.

-Final- Code 7714Sickle cell anemia is a kind of anemia where the red blood cells that carry the oxygen become shaped like a sickle (or a boomerang). Because of this, they are not able to carry as much oxygen to the body, and they sometimes get stuck in small blood vessels, blocking the blood flow to the tissues. A diagnosis of this condition alone is not enough to get a rating. There must be proof of significant symptoms that limit your ability to function in some way. This condition is genetic, and so it technically did exist prior to service (EPTS) and may not be ratable in some cases.

If there are 4 or more severe painful episodes each year, with blood clots, anemia, and other symptoms that all cause the condition to be severe enough that even light manual labor cannot be performed, then it is rated 100%. If there are 3 severe painful episodes each year with symptoms that restrict activity to just light manual labor, then it is rated 60%. If there are 1 or 2 severe painful episodes each year, then it is rated 30%. If the condition has been properly diagnosed and it affects some organs, but there are no symptoms, then it is rated 10%.

The only real change to this code is to specify the number of severe episodes that must occur each year to qualify under a particular rating. This will make it easier to make rating decisions for cases of sickle cell anemia.
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Code 7715Lymphomas that are not Hodgkin’s are rated under this code. Lymphomas are the growth of lymphoid cells in areas they are not meant to be. If the cancer is active or undergoing treatment, then it is rated 100%. This rating continues for 6 months following the last treatment. It is then reevaluated and re-rated based on the ongoing symptoms.

-Final- Code 7715Lymphomas that are not Hodgkin’s are rated under this code. Lymphomas are the growth of lymphoid cells in areas they are not meant to be. If the cancer is active and is in an indolent, slow growth, or non-contiguous stage or undergoing treatment, then it is rated 100%. This rating continues for 2 years following the last treatment. It is then reevaluated and re-rated based on the ongoing symptoms.

Two changes were made to this code. First, additions were added to clarify that even the lowest stage of non-Hodgkin’s lymphomas are rated at 100%, not just the more aggressive stages. Second, the 100%-rating period was changed from 6 months to 2 years because lymphomas are notorious for recurring, often after the 6-month period, but usually within 2 years. 
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Code 7716Aplastic anemia is a condition where the bone marrow does not make enough new blood cells. If the condition requires a bone marrow transplant, then it is rated 100%. This 100% rating will continue for 6 months following the transplant surgery. After this time, the condition will be reevaluated and rated on its need for continuing transfusions or medications as detailed below.

If the condition does not need a transplant, but requires a transfusion of red blood cells or platelets at least once every 6 weeks or if there are infections that occur at least every 6 weeks, then it is rated 100%. If it requires a transfusion at least once every 3 months or if there are infections occurring every 3 months, then it is rated 60%. If it requires a transfusion at least once a year or if there are infections occurring at least once a year, then it is rated 30%. If the condition at least requires continuous medication, then it is rated 10%.

-Final- Code 7716Aplastic anemia is a condition where the bone marrow does not make enough new blood cells. If the condition requires a bone marrow or peripheral blood stem cell transplant, then it is rated 100%. This 100% rating will continue for 6 months following discharge from the hospital. After this time, the condition will be reevaluated and re-rated.

If the condition does not need a transplant, but requires a transfusion of red blood cells or platelets at least once every 6 weeks each year on average or if there are infections that occur at least every 6 weeks each year on average, then it is rated 100%. 

If it requires a transfusion at least once every 3 months each year on average, or if there are infections occurring every 3 months each year on average, or if it requires continuous immunosuppressive or platelet stimulating therapy, then it is rated 60%. 

If it requires a transfusion at least once a year on average, or if there are infections occurring at least once a year on average, then it is rated 30%. 

The VA is updating this code to better reflect current treatments of aplastic anemia, including peripheral blood stem cell transplants. Also the terms “on average” were added to better standardize the rating options. Finally, the VA is getting rid of the 10% rating altogether, stating that any medications used to treat aplastic anemia qualify for a higher rating, and so the 10% rating will be obsolete. This is further justified by the fact that they added the requirement of immunosuppressive therapy to the 60% rating, thereby covering all the standard treatment options under the higher ratings. 
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No changes are being made to code 7717 for primary amyloidosis.
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-NEW CODE- Code 7718Essential thrombocythemia is a disease which causes the body to produce too many platelets, and primary myelofibrosis is a condition that interferes with the ability of the bone marrow to produce blood cells, thus resulting in abnormal cell and platelet levels. Both are rated under this code. 

If the condition requires a peripheral blood or bone marrow stem cell transplant, chemotherapy, orinterferon treatments, it is rated 100%. This 100% rating continues for 6 months following discharge from the hospital or following the last treatment. It is then reevaluated and re-rated by the VA.

A 100% rating is also given for the entire time the condition requires continuous myelosuppressive therapy. 

If the condition requires myelosuppressive therapy, chemotherapy, or interferon therapy to keep the platelet count less than 500,000,000,000/L (a.k.a. 500x109/L), it is rated 70%. 

If it requires myelosuppressive therapy, chemotherapy, or interferon therapy to keep the platelet count between 200,000 and 400,000 or to keep the white blood cell count between 4,000 and 10,000, it is rated 30%. A 0% rating is given if the condition is asymptomatic. 

If the condition turns into leukemia, it is then not rated under this code, but under code 7703. 

This is a new code the VA is creating to cover one of the myeloproliferative disorders (conditions that cause the overproduction of either white blood cells, red blood cells, or platelets) that have previously not been included in the VASRD. A different code is being created to cover each of the types of overproduction: 7704 for overproduction of red blood cells (not a new code, but adjusted), 7718 for overproduction of platelets, and 7719 for overproduction of white blood cells. 

When the VA first proposed creating this new code, the ratings they had were a bit different than the ones now given. Now, they include both chemo and interferon therapies on all rating levels. This is problematic, in that the requirements for the 100% level seem to be satisfied if the patient has chemo or interferon treatments at all, so how to distinguish the ratings in these situations is unclear. Unfortunately, the VA is not open to comments on these final changes, so hopefully the VA will figure it out and clarify this before December.
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-NEW CODE- Code 7719Chronic myelogenous leukemia (a.k.a. CML, chronic myeloid leukemia, or chronic granulocytic leukemia) is a cancer that causes the bone marrow to produce too many white blood cells. It is a form of leukemia, but because of its unique properties, there are different treatment options. CML can evolve into regular leukemia. If it does, then it is rated under code 7703 for all other leukemias.

If the condition requires a bone marrow or peripheral blood stem cell transplant or if it requires continuous myelosuppressive or immunosuppressive therapy (like radioactive phosphorus or chemotherapy), then it is rated 100%. This 100% rating continues for 6 months following the last treatment or discharge from the hospital. The condition is then reevaluated by the VA and re-rated. 

If the condition is not in apparent remission and requires interferon treatments, periodic myelosuppressive therapy, or molecularly-targeted therapy with tyrosine kinase inhibitors, it is rated 60%. 

If the condition is in apparent remission and requires continuous molecularly-targeted therapy with tyrosine kinase inhibitors, it is rated 30%. 

The VA is adding this code and separating the rating of chronic myelogenous leukemia from the rating of all other leukemias (code 7703). This separation is due primarily to the fact that CML can often be treated effectively by modern medications and treatments, thus keeping the seriousness of the condition at bay in many instances. Because of this, there are varying severities of CML that can last for significant periods of time, thus requiring appropriate ratings for the varying severities. 
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-NEW CODE- Code 7724Solitary plasmacytoma is a cancer of the plasma cells that develops in the bones. If caught early, the majority of solitary plasmacytomas are curable, but the majority can also turn into multiple myeloma. If the plasmacytoma develop into multiple myeloma, then it is rated under code 7712 as symptomatic multiple myeloma.

Treatments for solitary plasmacytoma can include surgery, radiation, chemotherapy, stem cell transplants, and other procedures. 

If the solitary plasmacytoma is active or being treated, it is rated 100%. The 100% rating continues for 6 months following the last treatment. The VA will then reevaluate and re-rate the condition. If the condition or its treatments cause other conditions, like thrombosis or neuropathy, then each can be rated separately. 

Like the previous code, the VA is giving solitary plasmacytoma its own code instead of rating it as multiple myeloma since it can be treated and even cured. 
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-NEW CODE- Code 7725Myelodysplastic syndromes are conditions in which the body does not produce enough of all types of blood cells. If the condition requires a bone marrow or peripheral blood stem cell transplant, or if it requires chemotherapy, it is rated 100%. This 100% rating continues for 6 months following the last treatment or discharge from the hospital. It will then be reevaluated and re-rated by the VA.

If the condition requires 4 or more blood or platelet transfusions each year, or if it causes 3 or more infections that require hospitalization each year, it is rated 60%. 

If the condition requires 1 to 3 blood or platelet transfusions each year, or if it causes 1 or 2 infections that require hospitalization each year, or if it requires ongoing biologic therapy, or if it requires erythropoiesis stimulating agent (ESA) for 12 weeks or less each year, it is rated 30%.

If the condition develops into leukemia, it is rated under code 7703. 

The VA is adding this code because myelodysplastic syndromes are fairly common in veterans, and the VASRD does not currently have a code that satisfactorily rates the treatment needs of these disorders.