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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. 

Wednesday, September 5, 2018

RAMP Opt-In Open to All Veterans with Pending Appeals

As promised back in April, the VA has finally released full details on how to opt-in to the RAMP program without having to wait and receive an official invitation.

If you are a veteran with a pending claim that has not yet been added to the BVA's docket, then you can submit the RAMP Opt-In form found on our Appeals Page. Make sure to follow the instructions in the included letter so that your application is complete and correct, including all supporting evidence needed for them to correctly process your claim.

This voluntary opt-in will only be available until February 2019 when the current appeals system will be completely replaced by the new RAMP program as part of the 2017 Appeals Modernization Act.

While there are still stories of veterans being unsatisfied with the new RAMP program, the program overall seems to be fairly successful to date. More than $45 million in retroactive benefits have been awarded and more than 73,000 appeals have been processed through the system (both RAMP and the BVA).

Hopefully this is a good sign for the future.

Monday, July 23, 2018

Official Changes to the Ratings of the Skin


On July 13th, 2018, the VA published their final changes to the ratings of the Skin (including Scars). 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 sixth to be made official and final.

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

Other proposed changes include the Hemic and Lymphatic System, the Genitourinary System, and the Musculoskeletal System.

The following Skin changes will go into effect August 13, 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 Skin conditions submitted on or after August 13th, however, any pending claims for Skin conditions submitted before this date will be considered under both the new and old criteria and given the highest rating allowed under either system. This could be a huge benefit to some veterans, so if you have yet to submit a claim for a skin condition, try to get it in before the 13th to give yourself a shot at the highest rating possible. 

On a positive note, two of the comments we submitted in response to the proposed changes were taken into consideration, and the VA made significant changes to the final codes based on our comments. It is great to know that our voices are being heard and changes being made for the better! Thank you for submitting your comments!

Now, the following are the VA’s final changes to the ratings for the Skin. The changes are fairly extensive, so I’ll walk through each, one at a time.

For each condition, the small, indented parts are 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 final changes. 
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First, a few changes to the overall system:

Systemic vs. Topical

The first change is to add a note that fully defines systemic vs. topical therapies for the treatment of skin conditions. As it is currently, it is a bit confusing what treatments are considered which due to the fact that some topical treatments can cause systemic reactions. Thus, to make it clear, the proposed change defines them as follows:

    - Systemic therapy is any treatment that is injected, or taken by mouth, through the nose, or anally. This includes, but is not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, and other immunosuppressive drugs.
- Topical therapy is any treatment applied directly to the skin, regardless of the type of drug. 

The VA reasons that these specifications allow for more fair ratings. If topical treatments of a very small skin area could qualify for a systemic rating, they would get an incredibly high rating for a fairly insignificant condition. On the other hand, in order for a topical treatment to cause systemic effects, it would have to be administered regularly over a very large area of the body. Because of this, a rating for the skin area alone would give a high enough rating to justify the severity of the condition.

Pyramiding Note

For these final changes, the VA decided that a note on how to apply the Pyramiding Principle to Skin conditions was necessary. 

Separate ratings can be given for multiple skin conditions as long as: 

1. each condition has a clear and distinct diagnosis
and
2. each condition affects a different area of skin

For a single condition that affects different skin areas, a single rating is given under that condition that takes into account all affected areas. For multiple conditions that affect the same area, the VA will rate only the one that gives the higher rating. 

Skin conditions and scars caused by those conditions cannot be rated separately unless specifically noted. 

Basic Rating System

The VA is also establishing a Basic Rating System that will be used to rate a number of skin conditions (though not all). The idea is that these conditions have similar enough symptoms, treatments, and overall disabilities that a single rating system would effectively rate each condition. 

The Basic Rating System

If the lesions (an area of rashes/bumps/scaly patches/etc.) cover more than 40% of total body or more than 40% of exposed divisions, orif it requires the constant or near-constant use of systemic therapy for the past 12 months, it is rated 60%. 

If the lesions cover 20 to 40% of total body or 20 to 40% of exposed divisions, orif it required the use of systemic therapy for a total of 6 weeks or more over the past 12 months, it is rated 30%. 

If the lesions cover 5 to 19% of total body or 5 to 19% of exposed divisions, orif it required the use of systemic therapy for a total of less than 6 weeks over the past 12 months, it is rated 10%. 

If the condition only required the use of topical medications over the past 12 months and the lesions cover less than 5% of total body or less than 5% of exposed divisions, it is rated 0%.

Now on to the codes.
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Code 7800 for scars or disfigurement of the head, face, and neck will not change.
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I’m going to discuss the changes for codes 7801, 7802, and 7805 together. These codes are fairly extensive, so I’m not going to reproduce the current ones here. Click on the linked codes just listed to go the discussion of them on our site. Here are the new changes:

Scars of the Body

Scars of the body are any scars that are not found on the head, face, and neck. 

Important! Each part of the body that is affected by a scar can be rated separately! Woo-hoo! For each kind of scar (deep, code 7801, superficial, code 7802, or other, code 7805), a single rating is given for each area of the body affected. These ratings are then combined using VA Math into a single overall scar rating assigned under the corresponding code. So if there are multiple scars or a single scar that affects more than one part of the body, then each is rated separately and then combined into a single overall rating for that kind of scar. For example, if a deep scar on the back is rated 30% and a deep scar on the stomach is rated 20%, the ratings would be combined using VA Math into a single 40% overall rating for deep scars. 

If, however, a higher rating can be achieved by adding the measurements for all of the scars in all the areas of the body together, then this rating can be given instead. For example, if there is a single deep scar that measures 6 inbut is divided between two areas (each 3 in2), then only a 0% would be given. But if the two areas are combined into 6 in2, then it would qualify for a 10% rating.

Below is a picture of the different areas of the body that can be rated separately. There are 6 areas in total, and they include the right arm, the left arm, the right leg, the left leg, the front of the torso, and the back of the torso. The front and back of the torso are separated by the midline on the side of the body. (The neck and head are rated under code 7800).




The ratings:

Code 7801: Deep scars are considered “deep” if there is damage to the soft tissues under the skin. If the area of scarring in a single body part is 144 in2or bigger, then it is rated 40%. If the area is between 72 in2and 144 in2, it is rated 30%. If the area is between 12 in2and 72 in2, then it is rated 20%. If it is between 6 in2and 12 in2, it is rated 10%.

Code 7802: Superficial scars are ones that only affect the skin, not the soft tissues underneath. If the area of scarring in a single body part is 144 in2or more, it is rated 10%. No other rating is given for superficial scars under this code.

Code 7805: All other scars are not ratable in and of themselves. If they cause another condition that makes it hard to properly do your job, however, then that other condition can be rated separately. For example, if a scar running up the arm makes it impossible to fully bend or straighten the arm at the elbow, then it is rated under limited motion of the elbow. The final code will look like this: 7805-3400. The first four-digit code defines the condition as a scar, and the second four-digit code tells how it is rated. 

The effects of scars rated under codes 7800-7804 but not covered by those ratings (like limited motion) can also be rated under this code.

The biggest change for these codes is getting rid of the differentiation between linear and non-linear scars. Under the current codes, linear scars are basically not ratable, even if they are considered deep. The final changes, however, allow for linear scars to be rated the same as non-linear scars. So a deep linear scar that measures at least 6 inwould qualify for a 10% rating instead of receiving nothing. 

The only other change is to allow all the areas of the body to be combined and then rated (instead of rated separately and then combined) if it would provide a higher rating. 
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Code 7804 for painful or unstable scars will not change.
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-Current- Code 7806Dermatitis and eczema are essentially the same thing, although some doctors might describe them slightly different. For rating purposes, however, they are treated the same. Basically, dermatitis is a condition where the skin swells and turns red—the standard rash. 

There are three different rating options for this condition. If the condition is so severe that it causes permanent scars, it can be rated as a scar condition under a scar code. The final code in that case would look like this: 7806-7801. The first four-digit code defines the condition as dermatitis, and the second four-digit code tells how it is rated. 

It can also be rated under this code either on calculations/estimations or on the required treatment of the condition itself. 

Calculations/estimations: If there is more than 40% of total body or more than 40% of exposed divisions affected, it is rated 60%. If there is 20 to 40% of total body or 20 to 40% of exposed divisions affected, it is rated 30%. If there is 5 to 20% of total body or 5 to 20% of exposed divisions affected, it is rated 10%. If there is less than 5% of total body or less than 5% of exposed divisions affected, it is rated 0%.

Treatments: If the condition required the almost constant use of oral or injected medications to regulate the immune system over the past 12 months (methotrexate, steroids, etc.), it is rated 60%. If the condition required oral or injected medications to regulate the immune system for a total of 6 weeks or more during the past 12 months, it is rated 30%. If the condition required oral or injected medications to regulate the immune system for a total of less than 6 weeks over the past 12 months, it is rated 10%. If the condition only required topical (put on the outside of the skin) medications over the past 12 months, it is rated 0%.

-Final- Code 7806: Dermatitis and eczema are essentially the same thing, although some doctors might describe them slightly different. For rating purposes, however, they are treated the same. Basically, dermatitis is a condition where the skin swells and turns red—the standard rash. 

This condition is either rated under the Basic Rating System, or as scars/disfigurement whichever best describes the disability. The final code in that case would look like this: 7806-7801. The first four-digit code defines the condition as dermatitis, and the second four-digit code tells how it is rated. 

In reality, the ratings for this code are not actually changing. 
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Code 7807 for New World (“American”) mucocutaneous leishmaniasis will not change.
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Code 7808 for Old World cutaneous leishmaniasis (“Oriental sore”) will not change.
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-Current- Code 7809Lupus is a condition where the immune system attacks the healthy cells of the skin, causing severe sores, tearing, and scarring of the skin. Most often, these occur on the head near the ears, eyes, nose, lips and cheeks, but in some cases lupus sores can affect other areas of the body. Lupus is either rated as dermatitis or as scars/disfigurement, whichever best describes the disability. The final code will look like this: 7809-7801. The first four-digit code defines the condition as lupus, and the second four-digit code tells how it is rated. 

If the lupus affects parts of the body besides the skin, then it is rated under code 6350 for systematic lupus erythematosus. A rating cannot be given under both codes. Only one or the other. 

-Final- Code 7809: Lupus is a condition where the immune system attacks the healthy cells of the skin, causing severe sores, tearing, and scarring of the skin. Most often, these occur on the head near the ears, eyes, nose, lips, and cheeks, but in some cases lupus sores can affect other areas of the body.

This condition is either rated under the Basic Rating System, or as scars/disfigurement whichever best describes the disability. The final code in that case would look like this: 7809-7801. The first four-digit code defines the condition as lupus, and the second four-digit code tells how it is rated. 

If the lupus affects parts of the body besides the skin, then it is rated under code 6350 for systematic lupus erythematosus. A rating cannot be given under both codes. Only one or the other. 

Subacute cutaneous lupus erythematosus is rated under code 7821

Again, the ratings for this code won’t change at all since the Basic Rating System is the dermatitis rating system and the scar option still applies. 

The main change is to move the rating of subacute cutaneous lupus erythematosus to code 7821. Right now, it is rated here, but based on more thorough and modern medical knowledge, the VA is moving the rating of subacute cutaneous lupus erythematosus to code 7821 because the condition is actually closer to collagen-vascular disease than this lupus. 
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Code 7811 for tuberculosis luposa will not change.
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-Current- Code 7813Dermatophytosis (“ringworm”) is a fungal infection that causes ring-shaped red and swollen patches on the skin. This condition is either rated under dermatitis, or scars/disfigurement whichever best describes the disability. The final code will look like this: 7813-7801. The first four-digit code defines the condition as dermatophytosis, and the second four-digit code tells how it is rated.

-Final- Code 7813: Dermatophytosis (“ringworm”) is a fungal infection that causes ring-shaped red and swollen patches on the skin. 

This condition is either rated under the Basic Rating System, or as scars/disfigurement whichever best describes the disability. If rated on scars/disfigurement, the final code will look like this: 7813-7801. The first four-digit code defines the condition as dermatophytosis, and the second four-digit code tells how it is rated.

Again, the ratings for this code aren’t changing at all since the Basic Rating System is the dermatitis rating system and the scar option still applies. 

The VA does specify a few additional conditions that are rated under this code, namely onychomycosis and tinea versicolor, but these are forms of dermatophytosis and so are rated here already anyway. All of the various kinds of dermatophytosis are rated here.
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-Final- Code 7815Bullous disorders cause blisters of clear liquid to form in between the layers of the skin, most often on the inner thighs and upper arms. 

This condition is either rated under the Basic Rating System, or as scars/disfigurement whichever best describes the disability. If rated on scars/disfigurement, the final code will look like this: 7815-7801. The first four-digit code defines the condition as a bullous disorder, and the second four-digit code tells how it is rated.

If the condition causes symptoms that affect other parts of the body besides the skin, it can be rated separately. So if it affects the lungs, it can receive a second rating under the lung code that best describes the symptoms, etc. 

This code has only a minor change, so I didn’t reproduce the original here. The only significant change to this code is the ability to rate additional symptoms under separate codes. Currently, no ratings are specified if the condition affects other areas of the body. 
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-Final- Code 7816Psoriasis is an autoimmune condition that tells the body to produce more skin cells even though they are not needed. This can cause numerous different things to happen to the skin, including redness, swelling, scaly texture, patches of red bumps, and more.

This condition is either rated under the Basic Rating System, or as scars/disfigurement whichever best describes the disability. If rated on scars/disfigurement, the final code will look like this: 7816-7801. The first four-digit code defines the condition as psoriasis, and the second four-digit code tells how it is rated.

If the condition causes symptoms that affect other parts of the body besides the skin, the symptoms can be rated separately. So if it causes psoriatic arthritis, it can receive a second rating under code 5002 for rheumatoid arthritis (psoriatic arthritis is rated as rheumatoid arthritis), etc. 

Like the last code, this code has only a minor change, so I didn’t reproduce the original here. The only significant change to this code is the ability to rate additional symptoms under separate codes. Currently, no ratings are specified if the condition affects other areas of the body. 
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-Current- Code 7817Exfoliative dermatitis (erythroderma) is a dermatitis that causes a scaly rash that covers the majority of the entire body. It is normally caused by another condition, like cancer or a reaction to a medication. If that condition is unfitting by itself, then the exfoliative dermatitis can only be rated as well if it contributes significantly to making the service member unfitting (super sensitive to motion, can’t wear his uniform, etc.). 

If the majority of the skin is affected andthings such as weight loss, fever, low protein in the blood, etc., are present, andcontinuous medications to regulate the immune system (methotrexate, steroids, etc.) were taken over the past 12 monthsorregular treatments of ultraviolet or other light wave/beam therapy were needed during the past 12 months, it is rated 100%. 

If the majority of the skin is affected, andcontinuous medications to regulate the immune system were taken over the past 12 months orregular treatments of ultraviolet or other light wave/beam therapy was needed during the past 12 months, it is rated 60%.

Regardless of how much skin is affected, if medications to regulate the immune system orultraviolet or other light wave/beam therapy were needed for a total of 6 weeks (does not need to be consecutive) or more during the past 12 months, it is rated 30%.

Regardless of how much skin is affected, if medications to regulate the immune system orultraviolet or other light wave/beam therapy were needed for a total of less than 6 weeks (does not need to be consecutive) or more during the past 12 months, it is rated 10%.

Regardless of how much skin is affected, if only topical treatments were used during the past 12 months, it is rated 0%.

-Final- Code 7817: Erythroderma is a dermatitis that causes a scaly rash that covers the majority of the entire body. It is normally caused by another condition, like cancer or a reaction to a medication. Because of this, it may already be covered under a rating for that condition. If not, it can be rated separately here.

If the majority of the skin is affected, there are systemic symptoms (weight loss, fever, low protein in the blood, etc.), andcontinuous systemic therapy (corticosteroids, immunosuppressive retinoids, biologics, etc.) or ultraviolet or other light wave/electron beam therapies were needed during the past 12 months, it is rated 100%. 

A 100% rating is also given if the same symptoms are present, but no treatment is currently being attempted since at least 2 treatment regimens failed in the past. The failed regimens must be clearly documented. In order to have “failed” the condition must have either gotten worse after the regimen or had less than 25% reduction in the severity after 4 weeks of treatment.

If the majority of the skin is affected andcontinuous systemic therapy or ultraviolet or other light wave/electron beam therapy was needed during the past 12 months, it is rated 60%. A 60% rating is also given if the majority of the skin is affected, but no treatment is currently being attempted since at least 1 treatment regimen failed in the past. The failed regimen must be clearly documented.

Regardless of how much skin is affected, if systemic or ultraviolet or other light wave/electron beam therapies were needed for a total of 6 weeks (does not need to be consecutive) or more during the past 12 months, it is rated 30%.

Regardless of how much skin is affected, if systemic or ultraviolet or other light wave/electron beam therapies were needed for a total of less than 6 weeks (does not need to be consecutive) during the past 12 months, it is rated 10%.

Regardless of how much skin is affected, if only topical treatments were used during the past 12 months, it is rated 0%.

The first change to this code is to get rid of “exfoliative dermatitis” from the title since it is a dated term that is no longer used for this condition. The VA also more clearly specified and included new systemic treatment options in the rating criteria. Finally, the VA added a rating option to compensate those veterans who are not undergoing treatment because previous treatments had failed. In the majority of these cases, the treatment failure is caused by the severity of the underlying condition and treatment failure of that condition. These cases currently cannot be rated although their condition is significant. 
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Code 7818 for malignant cancer of the skin will not change.
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Code 7819 for benign tumors will not change.
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-Current- Code 7820All other infections of the skin that are not listed elsewhere are rated under this code. These conditions are either rated as dermatitis or as scars/disfigurement, whichever best describes the disability. The final code will look like this: 7820-7801. The first four-digit code defines the condition as a skin infection, and the second four-digit code tells how it is rated.

-Final- Code 7820: All other infections of the skin that are not listed elsewhere are rated under this code.

These conditions are either rated under the Basic Rating System, or as scars/disfigurement, whichever best describes the disability. If rated on scars/disfigurement, the final code will look like this: 7820-7801. The first four-digit code defines the condition as a skin infection, and the second four-digit code tells how it is rated.
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-Current- Code 7821Cutaneous manifestations of collagen-vascular diseases are skin conditions that occur when the immune system attacks the collagen. Collagen is the proteins that are in the skin. Psoriasis is considered a collagen-vascular disease. This code is used to rate any collagen-vascular disease that is not listed elsewhere on this page.

-Final- Code 7821: Cutaneous manifestations of collagen-vascular diseases are skin conditions that occur when the immune system attacks the collagen. Collagen is the proteins that are in the skin. Psoriasis is considered a collagen-vascular disease. This code is used to rate any collagen-vascular disease that is not listed elsewhere on this page, including subacute cutaneous lupus erythematosus.

These conditions are either rated under the Basic Rating System, or as scars/disfigurement, whichever best describes the disability. If rated on scars/disfigurement, the final code will look like this: 7821-7801. The first four-digit code defines the condition as a cutaneous manifestation of a collagen-vascular disease, and the second four-digit code tells how it is rated.

The main change for this code is to include subacute cutaneous lupus erythematosus instead of it being rated under code 7809. The ratings themselves, although reformatted as the Basic Rating System, do not change. 
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-Final- Code 7822Any other skin conditions that cause hard, scaly bumps (“papulosquamous disorders”) to form on the skin that are not listed anywhere else on this page are rated under this code, including mycosis fungoides, lichen planus, plaque parapsoriasi, PLEVA, PRP, lymphomatoid papulosus, and more. 

This condition is either rated under the Basic Rating System, or scars/disfigurement whichever best describes the disability. If rated on scars/disfigurement, the final code will look like this: 7822-7801. The first four-digit code defines the condition as a papulosquamous disorder, and the second four-digit code tells how it is rated.

Besides adjusting things for the Basic Rating System, the primary change to this code is to further clarify some of the specific conditions rated under this code, specifically mycosis fungoides, which is often misrated under other codes. 
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Code 7823 for vitiligo will not change.
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-Current- Code 7824Diseases of keratinization affect the process where the lower layers of the skin turn into the harder outer layer of skin. Keratin is the protein that causes the skin to harden. Any condition that affects the process of keratinization is rated under this code. 

If the condition affects the whole body and required almost constant oral or injected medication over the past 12 months, it is rated 60%. If the condition affects the whole body and required the use of oral or injected medication for a total of at least 6 weeks during the past 12 months, it is rated 30%. If the condition only affects some areas of the body and required the use of oral or injected medication for a total of less than 6 weeks during the past 12 months, it is rated 10%. If only topical treatments were required during the past 12 months, it is rated 0%.

-Final- Code 7824: Diseases of keratinization affect the process where the lower layers of the skin turn into the harder outer layer of skin. Keratin is the protein that causes the skin to harden. Any condition that affects the process of keratinization is rated under this code. These conditions are rated under the Basic Rating System.

The only change to this code is to have it solely rated under the Basic Rating System. 
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-Current- Code 7825Chronic hives are pale red, itchy bumps on the skin that are caused either by allergic reactions or various other causes. To qualify as chronic, they must last for 6 weeks or more. If there were severe debilitating (it’s impossible to do your job) episodes that occurred at least 4 times over the past 12 months that cannot be controlled by treatment, it is rated 60%. If there were severe debilitating episodes that occurred at least 4 times over the past 12 months but it could be controlled by medications that regulate the immune system (methotrexate, steroids, etc.) it is rated 30%. If there were episodes (not debilitating) that occurred at least 4 times over the past 12 months, but the condition could be controlled by medications that control swelling, it is rated 10%.

-Final- Code 7825: Chronic hives (urticaria) are pale red, itchy bumps on the skin that are caused either by allergic reactions or various other causes. 

To qualify as “chronic,” the hives must occur at least twice per week for at least 6 weeks or more without treatment.

Chronic hives that requires third line treatment (plasmapheresis, immunotherapy, immunosuppressives, etc.) for control because lesser medications were ineffective (“refractory”) is rated 60%. 

Chronic hives that requires second line treatment (corticosteroids, sympathomimetics, leukotriene inhibitors, neutrophil inhibitors, thyroid hormone, etc.) for control is rated 30%.

Chronic hives that requires first line treatment (antihistamines) for control is rated 10%. 

The VA made significant changes to this code from what they originally proposed because of a comment we submitted. In order to ensure that someone with continuous, severe urticarial is properly rated, the use of episodes was not effective. Instead, this more appropriate definition of chronic allows for a wider range of conditions to be properly rated. 

These final changes also use not only the presence of chronic urticaria, but also the types of medication necessary to control the symptoms.  
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-Current- Code 7826Primary cutaneous vasculitis is a condition of the small blood vessels near the skin, which causes them to burst. The skin turns red or purple due to bleeding under the skin. If this condition is caused by other conditions, like infections, medications, cancer, autoimmune disorders, etc., it can only be rated as that condition. If it is not caused by another condition, then it can be rated here. Likewise, if the condition caused significant scarring, it can be rated under the scar codes. Choose the one rating system that would give the highest rating. 

If there were at least 4 debilitating (can’t perform your job) episodes over the past 12 months that did not respond to treatment, it is rated 60%. If there were at least 4 debilitating episodes over the past 12 months that were controlled by medications that regulate the immune system (methotrexate, steroids, etc.), then it is rated 30%. If there were 1 to 3 episodes (not debilitating) over the past 12 months that were controlled by medications that regulate the immune system, then it is rated 10%. 

-Final- Code 7826: Primary cutaneous vasculitis is a condition of the small blood vessels near the skin, which causes them to burst. The skin turns red or purple due to bleeding under the skin. If this condition is caused by other conditions, like infections, medications, cancer, autoimmune disorders, etc., it can only be rated as that condition. If it is not caused by another condition, then it can be rated here. Likewise, if the condition caused significant scarring/disfigurement, it can be rated under the scar codes instead. Choose the rating system that would give the highest rating.

An “episode” is a period of active symptoms. All episodes must be medically documented to count towards a rating.

If there are regular and consistent episodes where the symptoms do not properly respond to continuous medications that supress the immune system, it is rated 60%. 

If there were 4 or more episodes during the past 12 months that required systemic medications to suppress the immune system (steroids, cyclosporine, etc.) to control them, it is rated 30%. 

If there were 1 to 3 episodes during the past 12 months that required systemic medications to suppress the immune system (steroids, cyclosporine, etc.) to control them, it is rated 10%.

A 10% rating is also given if there are no documented episodes because it is sufficiently controlled by continuously taking systemic medications.

Similar to the changes for hives, the VA is getting rid of “debilitating episodes” and replacing it with “episodes.” The episodes will now not have to be specifically noted as debilitating. The VA also adds one additional rating criteria for the 10% rating in order to more completely cover the level of disability presented by conditions that are controlled successfully by constant medication. This broadens the number of cases that will be able to qualify for a rating under this code. 
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-Current- Code 7827Erythema multiforme and toxic epidermal necrolysis (“TENs”) are either caused by an infection or are reactions to medication. They cause red skin rashes and bumps to appear all over the body. They then attacks and kills the skin all over the body, causing the top layer of skin to detach from the lower layers all over the body, which can send the organs into failure. If the condition caused significant scarring, it can either be rated under the scar codes or this code. Choose the one that would give the highest rating.

If there were severe debilitating (it’s impossible to do your job) episodes that occurred at least 4 times over the past 12 months that could not be controlled by treatment, it is rated 60%. If there were episodes (not debilitating) that occurred at least 4 times over the past 12 months but it could be controlled by medications that regulate the immune system, it is rated 30%. If there were episodes (not debilitating) that occurred 2 or 3 times over the past 12 months that were controlled by medications that control swelling, it is rated 10%. A 10% rating is also given if there were 1 to 3 episodes that occurred over the past 12 months that were controlled by medications that regulate the immune system. 

-Final- Code 7827: Erythema multiforme and toxic epidermal necrolysis (“TENs”) are both rated under this code. Both are either caused by an infection or are reactions to medication. They cause red skin rashes and bumps to appear all over the body. They then attack and kill the skin all over the body, causing the top layer of skin to detach from the lower layers, which can send the organs into failure. Erythema multiforme is less severe than TENs, usually only affecting less than 10% of the body. If the condition causes significant disfigurement/scarring, it can either be rated under the appropriate scar code or this code, whichever gives the highest rating.

While both conditions can cause symptoms anywhere on the body, notable disabilities are caused when they affect the mouth (difficulty chewing), the hands (difficulty gripping), or the feet (difficulty walking). 

If the condition caused 4 or more episodes of mouth, hand, or foot impairment over the past 12 months despite taking constant medications that suppress the immune system, it is rated 60%. 

If it caused 4 or more episodes of mouth, hand, or foot involvement (but didn’t impair their functions) over the past 12 months that required occasional systemic treatments (immunosuppressives, antihistamines, or sympathomimetics), it is rated 30%. 

If it caused 1 to 3 episodes of mouth, hand, or foot involvement (but didn’t impair their functions) over the past 12 months that required occasional systemic treatments, it is rated 10%. 

A 10% rating is also given if there are no episodes, but it requires continuous systemic treatments to control the symptoms. 

The VA notes that for these conditions to be “debilitating” there must be mouth, hand, or foot involvement. So instead of using the vague phrase, they are instead changing the rating requirements to specify mouth, hand, or foot involvement and the severity of that involvement. 
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I’ll discuss both of the acne codes together. 

-Current- Code 7828: Acne is a skin condition that causes pus-filled raised bumps that can occur anywhere on the body. 

Code 7829: Chloracne is a condition where acne erupts over patches of skin that have come in contact with chemicals that contain dioxins. 

Some acne is very superficial, involving only one layer of the skin, while other acne can be very deep. Often acne causes scarring. If the scars are the main disability, then this condition can be rated under the scar codes

The ratings: If the acne is deep, causing inflammation and pus-filled cysts, and affects 40% or more of the face and neck, it is rated 30%. If the acne is deep, causing inflammation and pusy cysts, and affects less than 40% of the face and neck, orif deep acne is in areas other than the face and neck, it is rated 10%. If the acne is superficial, it is rated 0%. 

-Final- Code 7828: Acne is a skin condition that causes pus-filled raised bumps that can occur anywhere on the body. 

Some acne is very superficial, involving only one layer of the skin, while other acne can be very deep. Often, acne causes scarring. If the scars/disfigurement are the main disability, then this condition can be rated under one of the scar codes

If the acne is deep, causing inflammation and pus-filled cysts, and affects 40% or more of the face and neck, it is rated 30%. 

If the acne is deep, causing inflammation and pus-filled cysts, and affects less than 40% of the face and neck, orif deep acne is in areas other than the face and neck, it is rated 10%. 

If the acne is superficial, it is rated 0%.

Code 7829: Chloracne is a condition where acne erupts over patches of skin that have come in contact with chemicals that contain dioxins. 

Some chloracne is very superficial, involving only one layer of the skin, while other chloracne can be very deep. Often chloracne causes scarring. If the scars/disfigurement are the main disability, then this condition can be rated under one of the scar codes.

If the chloracne is deep, causing inflammation and pus-filled cysts, and affects 40% or more of the face and neck, it is rated 30%. 

A 20% rating is given if the chloracne is deep, causing inflammation and pus-filled cysts, and affects at least one of the following areas: the armpit, the genital region, the folds of the breast, and the areas between the fingers and toes.

If the chloracne is deep, causing inflammation and pus-filled cysts, and affects less than 40% of the face and neck, orif deep chloracne is in areas other than the face and neck or the areas noted above, it is rated 10%. 

If the chloracne is superficial, it is rated 0%. 

The only change to code 7828 for acne is to remove a term that is no longer used. In reality, nothing changes at all. 

For code 7829 for chloracne, however, the VA adds a new 20% rating for deep acne that is found in certain regions on the body. Deep, painful acne in these regions would cause a higher level of disability because of the difficulty of movement it would cause, so the VA feels that a 20% rating would more fully reflect the level of disability. 
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Code 7830 for scarring alopecia, code 7831 for alopecia areata, code 7832 for hyperhidrosis, and code 7833 for malignant melanoma will not change.