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Friday, August 26, 2016

Proposed Changes to the Ratings of the Skin are Now Open to Comments

On August 12th, 2016, the VA published their proposed changes to the ratings of the Skin (including Scars). This is the seventh set of changes that has been proposed as part of the VA’s complete rewrite of the VASRD which is supposed to be done by the end of 2016, but has been significantly delayed. Previously published changes include the Hemic and Lymphatic System, Mental Disorders, the Female Reproductive System, The Eyes, the Endocrine System, and Dental and Oral Conditions.

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 15th, 2016. 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 Female Reproductive System. 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 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 proposed changes.

First, a few changes to the overall system:

The first proposed 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.

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.

The second proposed change is to create a Basic Rating System that would 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. So here is the proposed system:

The Basic Rating System

If the condition covers more than 40% of total body or more than 40% of exposed divisions affected, or if it requires the constant or near-constant use of systemic therapy for 12 months, it is rated 60%.

If the condition covers 20 to 40% of total body or 20 to 40% of exposed divisions affected, or if it requires the use of systemic therapy for a total of 6 weeks or more every 12 months, it is rated 30%.

If the condition covers 5 to 20% of total body or 5 to 20% of exposed divisions affected, or if it requires the use of systemic therapy for a total of less than 6 weeks every 12 months, it is rated 10%.

If the condition covers less than 5% of total body or less than 5% of exposed divisions affected, or if it requires only topical medications every 12 months, it is rated 0%.

Note: The VA proposes changing the terminology of the VASRD from “during the past 12-month period” to “per 12-month period.” They say this change adds clarity, but in reality, it doesn’t. With this change, it isn’t clear whether or not that means the past 12 months, or any 12-month period during the past 20 years. For the purposes of this blog, I’ve interpreted it as “every 12 months”, but acknowledge that this probably isn’t really what they meant either since their discussions often still say “past 12 months.” This is a definite issue that they need to clearly clarify before publishing the final changes, and one that I will be addressing in the comments we submit. Just note that anytime in this blog that I say “every 12 months”, the real meaning is still to be determined. I think the most logical interpretation is still the “past 12 months,” but since they made a big to-do about changing it, I couldn’t just leave it as is.

Now on to the codes.
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Code 7800 for scars or disfigurement of the head, face, and neck remains exactly the same.
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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 proposed codes:

-Proposed- 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 in2 but 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).




Time for 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 in2 or bigger, then it is rated 40%. If the area is between 72 in2 and 144 in2, it is rated 30%. If the area is between 12 in2 and 72 in2, then it is rated 20%. If it is between 6 in2 and 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 in2 or 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, then that other condition is rated. So, for example, if a linear 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 linear scar, and the second four-digit code tells how it is rated.

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 pretty much not ratable, even if they are considered deep. The proposed 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 in2 would 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 remains exactly the same.
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-Current- 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.

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%.

-Proposed- 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 rated on the Basic Rating System. If, however, 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.

In reality, the proposed changes don’t change the ratings themselves for this code. The new Basic Rating System gives the same ratings it currently has.
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Code 7807 for New World (“American”) mucocutaneous leishmaniasis remains exactly the same.
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Code 7808 for Old World cutaneous leishmaniasis (“Oriental sore”) remains exactly the same.
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-Current- 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. 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.

-Proposed- 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 rated on the Basic Rating System. If, however, 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: 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 don’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 wants to move 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 remains exactly the same.
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-Current- 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 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.

-Proposed- 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 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 don’t change 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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-Proposed- Code 7815: Bullous 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 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.

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 given if the condition affects other areas of the body.
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-Proposed- Code 7816: Psoriasis 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 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, it can be rated separately. So if it causes psoriatic arthritis, it can receive a second rating under code 5002 for 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 given if the condition affects other areas of the body.
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-Current- Code 7817: Exfoliative 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 and things such as weight loss, fever, low protein in the blood, etc., are present, and continuous medications to regulate the immune system (methotrexate, steroids, etc.) were taken over the past 12 months or regular 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, and continuous medications to regulate the immune system were taken over the past 12 months or regular 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 or ultraviolet 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 or ultraviolet 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%.

-Proposed- 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. 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 and things such as weight loss, fever, low protein in the blood, etc., are present, and either 1.) continuous systemic treatments (corticosteroids, immunosuppressive retinoids, biologics, etc.) were taken over the past 12 months or 2.) regular treatments of ultraviolet or other light wave/electron beam therapy were needed during the past 12 months, it is rated 100%. A 100% rating is also given if 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, and either 1.) continuous systemic treatments were taken over the past 12 months or 2.) regular treatments of 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 no treatment is currently being attempted since 1 treatment regimen failed in the past. The failed regimen must be clearly documented.

Regardless of how much skin is affected, if systemic treatments or ultraviolet or other light wave/electron 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 systemic treatments or ultraviolet or other light wave/electron 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%.

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 really 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 remains exactly the same.
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Code 7819 for benign tumors remains exactly the same.
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-Current- Code 7820: All 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.

-Proposed- 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.

The only change to this code is to include the Basic Rating System. No real effect on the ratings themselves.
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-Current- 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.

-Proposed- 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.

This condition is rated on the Basic Rating System. If, however, 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: 7821-7801. The first four-digit code defines the condition as 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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-Proposed- Code 7822: Any 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 remains exactly the same.
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-Current- 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.

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%.

-Proposed- 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.  This condition is 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 7825: Chronic 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%.

-Proposed- Code 7825: Chronic 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 and recur occasionally. An “attack” is a single period of chronic hives that lasts at least 6 weeks. All attacks must be officially medically documented to count towards a rating.

If there are 4 or more attacks every 12 months that cannot be controlled by treatment, it is rated 60%.

If there are 4 or more attacks every 12 months that can be controlled by medications that supress the immune system (steroids, cyclosporine, etc.), it is rated 30%.

If there are 1 to 3 attacks every 12 months that can be controlled by medications that supress the immune system, it is rated 10%.

A 10% rating is also given if there are 4 or more attacks every 12 months that are treated by antihistamines or sympathomimetics, or if there are no documented attacks because it is sufficiently controlled by continuously taking medications that supress the immune system.

The VA proposes a number of changes to the ratings for hives. Currently, the ratings are based on debilitating episodes. To make the requirements more clear, the VA proposes using “attacks” instead of “debilitating episodes.” Basically, as long as a period of hives of 6 weeks or more is officially documented, it counts as an attack. It does not have to be specifically noted as debilitating.

More significantly, the VA adds two additional rating criteria for the 10% rating in order to more completely cover the level of disability presented by conditions that are only treated with “less severe” medications or 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 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, 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%.

-Proposed- 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, it can be rated under the scar codes. Choose the one 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 are 4 or more episodes every 12 months that can be controlled by medications that suppress the immune system (steroids, cyclosporine, etc.), it is rated 30%.

If there are 1 to 3 episodes every 12 months that can be controlled by medications that suppress the immune system, it is rated 10%.

A 10% rating is also given if there are no documented episodes because it is sufficiently controlled by continuously taking medications that suppress the immune system.

Similar to the changes for hives, the VA proposes to get rid of “debilitating episodes” and replace it with “episodes.” It does 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 7827: Erythema multiforme (toxic epidermal necrolysis, “TENs”) is either caused by an infection or is a reaction to medication. It causes red skin rashes and bumps to appear all over the body. It 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.

-Proposed- 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 scarring, it can either be rated under the scar codes 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 (difficult gripping), or the feet (difficulty walking).

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

If it causes 4 or more episodes of mouth, hand, or foot involvement (but doesn’t impair their functions) every 12 months that require occasional systemic treatments (immunosuppressives, antihistamines, or sympathomimetics), it is rated 30%.

If it causes 1 to 3 episodes of mouth, hand, or foot involvement (but doesn’t impair their functions) every 12 months that require 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 instead propose to change 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 puss-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 puss-filled cysts, and affects 40% or more of the face and neck, it is rated 30%. If the acne is deep, causing inflammation and pussy cysts, and affects less than 40% of the face and neck, or if deep acne is in areas other than the face and neck, it is rated 10%. If the acne is superficial, it is rated 0%.

-Proposed- Code 7828: Acne is a skin condition that causes puss-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 are the main disability, then this condition can be rated under the scar codes.

If the acne is deep, causing inflammation and puss-filled cysts, and affects 40% or more of the face and neck, it is rated 30%. If the acne is deep, causing inflammation and puss-filled cysts, and affects less than 40% of the face and neck, or if 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 are the main disability, then this condition can be rated under the scar codes.

If the chloracne is deep, causing inflammation and puss-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 puss-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 puss-filled cysts, and affects less than 40% of the face and neck, or if 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 proposed change to code 7828 for acne is to remove the 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 all remain exactly the same.