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Wednesday, September 18, 2019

Cardiovascular System Changes Comments

The following are the comments we submitted on your behalf to the VA in regards to the proposed changes to the ratings of the Cardiovascular System

Every time the VA publishes their proposed changes for a section of the VASRD, they include a comment period in which veterans and organizations can provide feedback on the coming changes. Thank you for submitting your comments to us regarding the Cardiovascular System so that we could submit them in a unified front to the VA. Hopefully, we will be able to effect change and make the rating system fairer for all veterans. 

Here are the comments we submitted for the Cardiovascular System: 

We at www.MilitaryDisabilityMadeEasy.com would like to submit the following comments on behalf of our staff and veterans in response to the proposed changes to the ratings for the Cardiovascular System. 

Item #1

For Code 7019, please clarify the one-year time periods required for the rating and the mandatory evaluation. It doesn’t make sense to have two different one-year time periods for this code. The 100% rating starts on the date of admission to the hospital while the mandatory examination is 1-year from the date of discharge. If the 100% rating can only be for a year, then immediately upon its end, a re-evaluation must take place in order to provide a new rating. If this is to account for the amount of time the person is hospitalized, it might be better to have the 100% start upon admission saying nothing about the 1-year limit. Then specify that the 100% rating will only continue for 1-year following discharge whereupon there must be a mandatory evaluation in order to award the new rating. 

Item #2

For Code 7110, there is a bit of confusion regarding that “ands” and “ors” in this code. The first part separates the size of the aneurysm from the need for symptoms or surgery, suggesting that the size itself rates 100%. If it is smaller, but causes symptoms and requires surgery, then it is also rated 100%. The 0% code, however, also includes an “or” that would make rating confusing. The wording suggests that any aneurysm less than 5 cm is rated here regardless of the severity of symptoms. Does that mean that a small aneurysm requiring surgery is only rated 0%? Clearly not, so an adjustment in the language would help clarify how these ratings should be applied to ensure proper rating. Potentially, “If less than 5 cm and surgical correction not recommended.”


Thanks for considering these comments.

Saturday, August 3, 2019

Proposed Changes to the Ratings of the Cardiovascular System


On August 1st, 2019, the VA published a new section of proposed VASRD changes, this time to the ratings of The Cardiovascular System (The Heart and The Arteries and Veins).

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 Infectious Diseases, Immune Disorders, and Nutritional Deficiencies, 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 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 September 30th, 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. 

The following are the VA’s proposed changes to the ratings for the Cardiovascular System. 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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The majority of heart conditions are rated based on a set rating system.

Note: It is very important that the physician performing your exam gets an MET (metabolic equivalent of task) test done for ANY heart condition. An MET test, more often known as an exercise test, checks for how much oxygen is being used by the body to perform increasingly strenuous tasks. 1 MET equals the amount of oxygen a person uses when at rest. An MET test is only not required if it is medically contraindicated or if a 100% rating can be made without it. For all other cases, it is essentialto getting a proper heart rating. Be proactive and make sure an MET test is done!

It is also vital that the need for medication for the condition and whether or not there is hypertrophy or dilation is clearly recorded by the physician.

The basic rating system:

A 100% rating is given if an MET test results in 3.0 METs or less and causes symptoms like shortness of breath, fatigue, chest pain, dizziness, heart palpitations, arrhythmia, or fainting.

A 60% rating is given if an MET test results in 3.1 to 5.0 METs and causes symptoms like shortness of breath, fatigue, chest pain, dizziness, heart palpitations, arrhythmia, or fainting.

A 30% rating is given if there is one or more of the following:
1) An MET test results in 5.1 to 7.0 METs and causes symptoms like shortness of breath, fatigue, chest pain, dizziness, heart palpitations, arrhythmia, or fainting.
2) Evidence (echocardiogram, multigated acquisition scan, MRI, etc.) of hypertrophy or dilatation. 

A 10% rating is given if there is one or more of the following:
1) An MET test results in 7.1 to 10.0 METs and causes symptoms like shortness of breath, fatigue, chest pain, dizziness, heart palpitations, arrhythmia, or fainting.
2) Continuous medication is required.

The VA is proposing to adjust the Basic Heart Rating System by focusing mostly on MET test results and removing congestive heart failure and ejection fractions as rating options. This is because both congestive heart failure and ejection fractions can be affected by things unrelated to the heart condition itself. Instead, an MET test gives a more accurate reflection of the heart condition itself.
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Codes 7000 for valvular heart disease, 7001 for endocarditis, 7002 for pericarditis, 7003 for pericardial adhesions, 7004 for syphilitic heart disease, 7005 for coronary artery disease, code 7006 for myocardial infarction, code 7007 for hypertensive heart disease, code 7008 for hyperthyroid heart disease remain exactly the same.
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-Proposed NEW CODE- Code 7009: Bradycardia (i.e., bradyarrhythmia, including sinus bradycardia, sinoatrial block, atrioventricular junctional escape rhythm, AV heart block or dissociation, atrial fibrillation/flutter, and idioventricular escape rhythm) is an abnormally slow heart rate below 60 beats per minute (bpm). 

If the condition requires the implantation of a permanent pacemaker, it is rated 100% for the first month after discharge from the hospital and then rated on the Basic Rating System.

As long as the condition causes clear symptoms, it is rated on the Basic Rating System. If there are no symptoms, then the condition cannot be considered service-connected.

The VA proposes to add this new code to cover all cases of bradycardia. This will be very beneficial as there is currently not a decent code to analogously rate these conditions, making rating choices difficult and inconsistent. Bradycardia isn’t always a problematic condition, however. Healthy, athletic adults and people sleeping often have low heart rates with no negative symptoms. Because of this, only cases of bradycardia that cause negative symptoms can be considered a service-connected disability.
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-Current- Code 7010: Supraventricular arrhythmias are abnormal heart rhythms, most commonly too fast, that are located in the heart’s two upper chambers. If episodes of abnormal heart rhythms occur 5 or more times a year, then it is rated 30%. A 10% rating is given if episodes of abnormal rhythm occur 1 to 4 times a year or if there is permanent atrial fibrillation with no evidence of other heart diseases or conditions. All episodes must be properly documented by an ECG test.

-Proposed- Code 7010: All types of Supraventricular tachycardia are rated under this code. These are abnormal heart rhythms, most commonly too fast, that are located in the heart’s two upper chambers. The condition must be confirmed by an ECG test.

If the condition requires intravenous pharmacologic adjustment, cardioversion, and/or ablation to relieve symptoms 5 or more times a year, then it is rated 30%. If the condition requires intravenous pharmacologic adjustment, cardioversion, and/or ablation to relieve symptoms 1 to 4 times a year, then it is rated 10%.

The VA is proposing to change the name from arrhythmia, which could be any type of abnormal heart rhythm, to tachycardia, abnormally fast heart rhythms. This code has always been intended to be used just for tachycardias, and this change will help clarify that. The VA is also proposing to change the rating requirements from recorded episodes to required treatments. There can be episodes of tachycardia that do not cause any symptoms and so do not cause a measureable disability. By rating the condition based on needed treatments, the ratings will more properly reflect the disability caused by a symptomatic condition. 
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-Current- Code 7011: Sustained ventricular arrhythmias are abnormal heart rhythms, most commonly too fast, that are located in the heart’s two lower chambers. These rhythms can come and go and are usually treated with medication or electric therapy. This condition receives the 100% rating the entire time it is being treated in the hospital or the entire time an implantable defibrillator is in place. If a pacemaker is implanted, then it is rated under code 7018.

-Proposed- Code 7011: Sustained ventricular arrhythmias are abnormal heart rhythms, most commonly too fast, that are located in the heart’s two lower chambers. These rhythms can come and go and are usually treated with medication or electric therapy. This condition receives the 100% rating the entire time it is being treated in the hospital or the entire time an implantable defibrillator is in place. If a pacemaker is implanted, then it is rated under code 7018. Six months after discharge from the hospital, the condition will be re-evaluated and re-rated based on the Basic Rating System. 

The only change to this code is to establish a 6-month period after hospital discharge for a re-evaluation. 
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-Current- Code 7015: Atrioventricular block occurs when the electrical impulses that allow the different parts of the heart to communicate and function are blocked. This must be associated with other evidence of heart disease to be considered unfitting. It is rated on the basic rating system with one addition: if a pacemaker is required, it is rated 10%. 

-Proposed- Code 7015: Atrioventricular block occurs when the electrical impulses that allow the different parts of the heart to communicate and function are blocked. There are two different types of atrioventricular block: benign and non-benign. A benign condition is less severe and includes First-Degree and Second-Degree (Type I). It is rated on the Basic Rating System. A non-benign condition is much more severe and includes Second-Degree (Type II) and Third-Degree. If it requires a pacemaker, it is rated under code 7018.

The VA proposes to adjust these ratings to ensure that the severity of the condition is properly rated. Most, if not all, non-benign conditions require a permanent pacemaker, so it makes sense to rate it directly under code 7018. 
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Codes 7016 for heart valve replacement, and code 7017 for coronary bypass surgery remain exactly the same.
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-Current- Code 7018: Cardiac pacemakers are implanted if the rhythm of the heart is too slow. This condition is rated 100% for the first 2 months following the surgery. After that, it is rated under the base condition that caused the irregular heart rhythm: supraventricular arrhythmiasventricular arrhythmias, or an atrioventricular block. The minimum rating for a condition requiring a pacemaker is 10%. If a defibrillator is implanted, then it is rated under code 7011.

-Proposed- Code 7018: Cardiac pacemakers are implanted if the rhythm of the heart is too slow. This condition is rated 100% for the first month following discharge from the hospital after the surgery. After that, it is rated under the base condition that caused the irregular heart rhythm: supraventricular arrhythmiasventricular arrhythmias, or an atrioventricular block. The minimum rating for a condition requiring a pacemaker is 10%. If a defibrillator is implanted, then it is rated under code 7011.

The only change to this is to allow a 1 month 100% rating after hospital discharge following the surgery instead of 2 months after the surgery itself. The VA justifies this change by stating that new surgical techniques require a much shorter recovery period. Since less time is needed a month should cover most recovery needs. For those with more serious cases that need longer hospital stays, they’ll still be covered by the Hospital Ratings Principle that rates long hospital stays (21 days+) 100% anyway. 
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Codes 7019 for heart transplant, 7020 for cardiomyopathy, and 7101 for hypertension remain the same.
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-Current- Code 7110If an aneurysm in the aortic artery is corrected by surgery, then it is rated 100% from the day of admittance to the hospital. This rating continues for the first 6 months after discharge from the hospital. The condition is then reevaluated and rated accordingly. If the condition is active and causes symptoms such as pain or hemorrhaging, or if it is 5 centimeters or larger in diameter, then it is rated 100%. If the condition is serious enough that you cannot perform moderately strenuous activities (lifting weights or running), then it is rated 60%. If the condition does not qualify for these ratings, then it is rated based on the existing symptoms in the affected organ (e.g. if it caused erratic heart beats, then it would be rated as arrhythmia).

-Proposed- Code 7110: Aneurysms in the thoracic, abdominal, or ascending aortic artery are rated under this code. Aneurysms occur when the aorta significantly expands with the potential of bursting. 

If the aneurysm is 5 cm or larger, it is rated 100%. If it causes symptoms (like the inability to perform moderately strenuous activities for fear of rupture) and a physician recommends surgery, it is rated 100% from the date of the physician’s recommendation until 6 months after discharge following the surgery. After that, any remaining heart symptoms are rated on the Basic Rating System. All other symptoms can be rated separately on the body system affected. 

If the aneurysm is less than 5 cm and surgery is not recommended, it is rated 0%. 

The VA proposes to eliminate a 60% rating, stating that any condition causing symptoms is serious enough to need surgery to avoid a medical emergency and so should be rated 100%. The addition of the 0% rating allows conditions without symptoms to be increased more quickly if they worsen and require surgery quickly. 
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-Current- Code 7111If an aneurysm in any large artery (except the aortic artery) is surgically corrected, then it is rated 100% from the date of admission to the hospital. This rating continues for the first 6 months after discharge from the hospital. The condition is then reevaluated and rated accordingly. A 100% rating is given if there is pain in the limbs (claudication) and tears in the skin of the limbs from lack of oxygen orif there is pain in the limbs and the ankle brachial index is 0.4 or less.

A 60% rating is given if you cannot walk further than 25 yards without limping because of pain and one or more of the following: there is coldness in the limb that does not respond to warming methods, there are one or more tears in the skin of the limb, or the ankle brachial index is 0.5 or less.

A 40% rating is given if you have limping because of pain when walking between 25 and 100 yards and one or more of the following: there are 1.) changes to the hair, skin, or nails of the affected limb, or 2.) the ankle brachial index is 0.7 or less.

A 20% rating is given if you have limping because of pain when walking more than 100 yards and one or more of the following: the pulse in the limb is diminished, or the ankle brachial index is 0.9 or less.

Note: These ratings are for a single limb only. If more than one limb has an aneurysm, then rate each separately.

-Proposed- Code 7111: If an aneurysm in any large artery (except the aortic artery, above) causes symptoms (like the inability to perform moderately strenuous activities for fear of rupture), it is rated 100%. If a physician recommends surgery, it is rated 100% from the date of the physician’s recommendation until 6 months after discharge following the surgery. After that, it is rated under code 7114.  

These changes clarify how the 100% rating should be applied. By eliminating the remaining rating options and instructing for further ratings to be done under code 7114, the VA is hoping to simplify the process. Code 7114, for peripheral artery disease, causes similar symptoms as post-surgical aneurysms. 
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Code 7112 for small artery aneurysms remains the same.
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-Current- Code 7113: A traumatic arteriovenous fistula is an abnormal passageway between an artery and a vein. They are most often caused by penetrating wounds that affected nearby arteries or veins, thus causing the body to create a false passageway to continue blood flow. They can cause the heart to have to work harder to provide the necessary blood to all regions of the body, thus leading to various heart conditions. It can also cause loss of blood flow to the limbs resulting in pain, infection, swelling, skin changes, or amputation.

If the condition causes heart failure, then it is rated 100%. If the heart has not failed, but is enlarged with a rapid pulse and a wide pulse pressure, then it is rated 60%. If the heart is not affected, but in an arm there is swelling, stasis dermatitis, and either tears in the skin or a cellulitis infection, then it is rated 40%. If a leg has swelling, stasis dermatitis, and either tears in the skin or a cellulitis infection, it is rated 50%. If there is only swelling or stasis dermatitis in a leg, then it is rated 30%. If the swelling or stasis dermatitis is in an arm, it is rated 20%.

-Proposed- Code 7113: traumatic arteriovenous fistula is an abnormal passageway between an artery and a vein. They are most often caused by penetrating wounds that affected nearby arteries or veins, thus causing the body to create a false passageway to continue blood flow. They can cause the heart to have to work harder to provide the necessary blood to all regions of the body, thus leading to various heart conditions. It can also cause loss of blood flow to the limbs resulting in pain, infection, swelling, skin changes, or amputation.

If the condition causes heart failure, then it is rated 100%. If the heart has not failed, but is enlarged with a rapid pulse and a wide pulse pressure, then it is rated 60%. 

If the heart is not affected, there is constant swelling, stasis dermatitis, and either tears in the skin or a cellulitis infection in a leg then it is rated 50%. If the same symptoms are in an arm, it is rated 40%. 

If there is only constant swelling orstasis dermatitis in a leg, then it is rated 30%. If the same symptoms are in an arm, it is rated 20%.

The only real change to this code is to specify that the swelling must be chronic, or constant. 
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-Current- Code 7114: Arteriosclerosis obliterans (a.k.a. peripheral vascular disease) is the thickening and hardening of the tissues of a vessel that causes the vessel to narrow and develop blood clots. This condition most often affects the aortic artery in the abdomen and the small or medium vessels in the legs.

A 100% rating is given if there is pain in the limbs and tears in the skin of the limbs from lack of oxygen or if there is pain in the limbs and the ankle brachial index is 0.4 or less.

A 60% rating is given if you cannot walk further than 25 yards without limping because of leg pain (claudication) and one or more of the following: there is coldness in the limb that does not respond to warming methods, there are one or more tears in the skin of the limb, or the ankle brachial index is 0.5 or less.

A 40% rating is given if there is limping because of leg pain when walking between 25 and 100 yards and one or more of the following: there are 1.) changes to the hair, skin, or nails of the affected limb, or 2.) the ankle brachial index is 0.7 or less.

A 20% rating is given if there is limping because of leg pain when walking more than 100 yards and one or more of the following: the pulse in the limb is diminished, or the ankle brachial index is 0.9 or less.

Note: The above ratings are for a single limb only. If more than one limb is affected, then rate each separately.

-Proposed- Code 7114: Peripheral arterial disease is the thickening and hardening of the tissues of a vessel that causes the vessel to narrow and develop blood clots. This condition most often affects the aortic artery in the abdomen and the small or medium vessels in the legs. All symptoms remaining after an aortic bypass surgery or a large arterial bypass surgery are rated under this code.

For a 100% rating, there must be at least one of the following: 
·     ankle pressure less than 50mm Hg
·     toe pressure less than 30mm Hg
·     transcutaneous oxygen tension less than 30 mm Hg
·      ankle brachial index  0.39 or less

For a 60% rating, there must be at least one of the following: 
·     ankle pressure 50–65 mm Hg
·     toe pressure 30–39 mm Hg
·     transcutaneous oxygen tension 30–39 mm Hg
·      ankle brachial index is 0.40–0.53

For a 40% rating, there must be at least one of the following: 
·     ankle pressure 66–83 mm Hg
·     toe pressure 40–49 mm Hg
·     transcutaneous oxygen tension 40–49 mm Hg
·      ankle brachial index is 0.54–0.66

For a 20% rating, there must be at least one of the following: 
·     ankle pressure 84–99 mm Hg
·     toe pressure 50–59 mm Hg
·     transcutaneous oxygen tension 50–59 mm Hg
·      ankle brachial index is 0.67–0.79

Whichever test result allows for the higher rating is the test that should be used for rating purposes. 

Note: The above ratings are for a single limb only. If more than one limb is affected, then rate each separately.

The VA proposes to update the name of the condition to the one more commonly used today. They also propose to expand the rating options to include more wide-spread measurements that better reflect the overall disability of a condition. The ankle pressure is the systolic blood pressure measured at the ankle. The toe pressure is the systolic blood pressure measured in the big toe. The transcutaneous oxygen tension is a test that measures the amount of oxygen in the blood at the intercostal space on the foot.

The VA also makes it clear that symptoms remaining after large artery bypass surgery should be rated under this code. 
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-Current- Code 7115: Thrombo-angiitis obliterans (or “Buerger’s Disease”) is a disease where the blood vessels of the hands or feet become blocked due to the build up of plaque. It is mostly associated with the use of tobacco products. It causes pain and swelling in the hands and feet and could result in necessary amputation.

A 100% rating is given if there is pain in the limbs and tears in the skin of the limbs from lack of oxygen or if there is pain in the limbs and the ankle brachial index is 0.4 or less.

A 60% rating is given if you cannot walk further than 25 yards without limping because of leg pain (claudication) and one or more of the following: there is coldness in the limb that does not respond to warming methods, there are one or more tears in the skin of the limb, or the ankle brachial index is 0.5 or less.

A 40% rating is given if there is limping because of leg pain when walking between 25 and 100 yards and one or more of the following: there are 1.) changes to the hair, skin, or nails of the affected limb, or 2.) the ankle brachial index is 0.7 or less.

A 20% rating is given if there is limping because of leg pain when walking more than 100 yards and one or more of the following: the pulse in the limb is diminished, or the ankle brachial index is 0.9 or less.

Note: The above ratings are for a single limb only. If more than one limb is affected, then rate each separately.

-Proposed- Code 7115: Thrombo-angiitis obliterans (or “Buerger’s Disease”) is a disease where the blood vessels of the hands or feet become blocked due to the build up of plaque. It is mostly associated with the use of tobacco products. It causes pain and swelling in the hands and feet and could result in necessary amputation.

If the condition affects the legs, it is rated under code 7114. If the condition affects the arms, it is rated under the following system:

A 100% rating is given if there are tears in the skin, death of the tissues from lack of oxygen, continual coldness in the limb, trophic changes, pain with use, and a weak pulse in the arm. 

A 60% rating is given if there is continual coldness in the limb, trophic changes, pain with use, and a weak pulse in the arm.

A 40% rating is given if there are trophic changes, numbness in the fingertips, and a weak pulse in the arm.

A 20% rating is given if there is a weak pulse in the arm.

Trophic changes include thinning of the skin, skin atrophy, hair loss, tears in the skin, fingernail deformities, etc. 

Note: The above ratings are for a single arm only. If more than one arm is affected, then rate each separately.

The VA proposes to change this code to better reflect the unique affect it has on the arms. The legs would still be rated under the same rating system as code 7114, but the arms would get their own rating system. 
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Code 7117 for Raynaud’s Syndrome (a.k.a. “Raynaud’s phenomenon” or “secondary Raynaud’s”) remains exactly the same except to specify that only Raynaud’s syndrome can be rated under this code. Raynaud’s disease would be rated under the new code 7124, below.
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Codes 7118 for angioneurotic edema, 7119 for erythromelalgia, 7120 for varicose veins, and 7121 for post-phlebitic syndrome remain the same.
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-Current- Code 7122: Frostbite and other conditions caused by overexposure to the cold can cause permanent damage to the arteries, nerves, and veins and are rated on the persistent symptoms of the condition.

A 30% rating is given if there is joint pain, numbness or sensitivity to the cold in the area affected and two or more of the following: discoloration of the skin, abnormal nail growth, tissue loss, decreased ability to feel, hyperhidrosis, or other abnormalities proven by x-ray.

A 20% rating is given if there is joint pain, numbness or sensitivity to the cold in the area affected and one of the following: discoloration of the skin, abnormal nail growth, tissue loss, decreased ability to feel, hyperhidrosis, or other abnormalities proven by x-ray.

A 10% rating is given if there is only pain, numbness or sensitivity to the cold in the affected area.

These ratings are for individual parts affected. So if a foot and a hand are both affected, then they each receive a separate rating. This does not include individual toes or fingers—if one or more fingers or toes are affected, then it is just rated once on the hand or foot.

Any other conditions resulting from overexposure to the cold not listed under this code are to be rated separately, including amputations, carcinomas and neuropathies.

-Proposed- Code 7122: Frostbite and other conditions caused by overexposure to the cold can cause permanent damage to the arteries, nerves, and veins and are rated on the persistent symptoms of the condition.

A 30% rating is given if there is joint pain, numbness or sensitivity to the cold in the area affected and two or more of the following: discoloration of the skin, abnormal nail growth, tissue loss, decreased ability to feel, hyperhidrosis, inability to sweat, muscle atrophy, fibrosis, deformation of the toe or finger joints, loss of the pads in the toes or fingers, bone tissue death (necrosis), constant tears in the skin, carpal tunnel, tarsal tunnel, or other abnormalities proven by x-ray.

A 20% rating is given if there is joint pain, numbness or sensitivity to the cold in the area affected and one of the following: discoloration of the skin, abnormal nail growth, tissue loss, decreased ability to feel, hyperhidrosis, inability to sweat, muscle atrophy, fibrosis, deformation of the toe or finger joints, loss of the pads in the toes or fingers, bone tissue death (necrosis), constant tears in the skin, carpal tunnel, tarsal tunnel, or other abnormalities proven by x-ray.

A 10% rating is given if there is only pain, numbness orsensitivity to the cold in the affected area.

These ratings are for individual parts affected. So if a foot and a hand are both affected, then they each receive a separate rating. This does not include individual toes or fingers—if one or more fingers or toes are affected, then it is just rated once on the hand or foot.

Any other conditions resulting from overexposure to the cold not listed under this code are to be rated separately, including amputations, carcinomas and neuropathies.

The VA proposes to expand the list of symptoms that cold exposure can cause. 
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Code 7123 for soft tissue sarcoma will remain the same.
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-Proposed NEW CODE- Code 7124:  Raynaud’s Disease (a.k.a. “primary Raynaud’s phenomenon” or “primary Raynaud’s”) is a condition that causes the blood vessels in the fingers and toes, and sometimes the nose and ears, to narrow and restrict blood flow when the person is stressed, emotionally upset, or cold.

Only one rating can be given under this code, regardless of the number of body parts affected. 

“Characteristic attacks” describes a period of time, at least a few minutes long, in which the color of the fingers or toes change in at least one limb, occasionally with pain and numbness.

Trophic changes include thinning of the skin, skin atrophy, hair loss, tears in the skin, fingernail deformities, etc. 

A 10% rating is given if there are characteristic attacks and trophic changes. If there are characteristic attacks, but no trophic changes, it is rated 0%. 

Raynaud’s disease is a less severe condition than Raynaud’s syndrome. Currently, Raynaud’s disease can only be rated under Raynaud’s syndrome, but the rating requirements under that code do not really reflect Raynaud’s disease symptoms. To fix this and avoid rating confusion, the VA proposes to create a new code for Raynaud’s disease.
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Thursday, June 20, 2019

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

On June 18th, 2019, the VA published their final changes 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 also been made to the ratings of the Hematologic and Lymphatic Systems, the Skin, the Female Reproductive System, the Eyes, Dental and Oral Conditions, the EndocrineSystem, and Mental Disorders.

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

The following changes will go into effect August 11th, 2019, 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 Infectious Diseases, Immune Disorders, and Nutritional Deficiencies submitted on or after August 11th.

The following are the VA’s final 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 ones labeled -Current- 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 final changes and then VA’s justification.
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-NEW- 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 creating 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 6300: Asiatic 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.

-Final- 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 necrotizing fasciitis).  

Currently, this code only covers Asiatic cholera, which is caused by the Vibrio bacteria. This bacteria, however, can cause many other types of infections as well. To ensure that those infections are properly recognized and rated, the VA is changing this code to include all Vibrio infections. 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.

-Final - Code 6301Visceral 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 the final treatment once the disease is no longer active. It is then reevaluated, and any remaining side effects are rated separately. These side effects could include liver damage, bone marrow diseases, or leishmaniasis of the skin.

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 and dermal leishmaniasis 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.


-Final- 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 effects could include skin damage, nerve damage, or amputation.

The VA is adding 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.

-Final- 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 effects could include liver damage, spleen damage, renal disease, and central nervous system conditions.

The VA is now requiring proper tests to diagnose all cases of malaria before they can be rated. They are also 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.

-Final- 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 effects could include epididymitis and various lymphatic conditions.

The only 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.

-Final- 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. The VA is removing the three-month rating since this condition is usually easily treated and is 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.

-Final- 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.

-Final- 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 central nerve damage.

The VA is adding 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.

-Final- 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 change to this code is for it to be rated on the General Rating System.
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Code 6310 for syphilis remains exactly 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).

-Final- 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 if both are still present. (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).

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

The VA effectually only added a note to require the proper testing to confirm any recurrence.
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- 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 is adding 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 will allow 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.

-Final- 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, nervoussystem infections, spleen damage, arthritis, hearing loss, respiratoryinfections, and much more.

The VA is requiring the appropriate tests to diagnose the condition in order to ensure both proper rating and proper treatment, and is expanding the list of potential side effects.
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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.

-Final- Code 6317:  Rickettsial infections (including scrub typhus, erlichiosis, anaplasmosis, etc.) are rated under this code. These 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 is broadening the name of this 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 removing 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.

-Final- 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 is requiring 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.

-Final- 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 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 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 is 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 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 is adding a new code for shistosomiasis, a unique condition that is usually mild but can have significant disabling effects in some veterans. This code will allow those veterans affected to be properly rated.
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-NEW Code- Code 6329:  Hemorrhagic fevers (including dengue fever, yellow 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 is adding this new code to avoid having to rate these fevers analogously.  
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-NEW Code- Code 6330:  Campylobacter jejuni is a 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 is adding this new code to avoid having to rate it analogously. 
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-NEW 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, endocarditis, vascular infection, and osteomyelitis. 

The VA is adding this new code to avoid having to rate it analogously. 
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-NEW Code- Code 6333:  Salmonella infections (non-typhoid) is a 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 and more. 

The VA is adding this new code to avoid having to rate it analogously. 
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-NEW Code- Code 6334:  Shigella infections (including dysentery) are 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 is adding this new code to avoid having to rate it analogously. 
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-NEW 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. Side effects can include physical, functional, and cognitive conditions.

The VA is 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.

-Final- 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, the T4 cell count is between 200 and 500, or there are clear signs of depression or memory loss that interfere with the ability to work, a rating of 10% is 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 making a number of changes to this code to better rate HIV based on current medical understandings and treatments. The VA is 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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Code 6354 for chronic fatigue syndrome will remain the same. The VA originally proposed making significant changes to this code and the diagnosis criteria for CFS back in February. However, they received enough comments refuting the lack of evidence supporting the proposed changes that the VA decided to not making any adjustments to this code until additional research can be performed to best know how to update these ratings.