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Wednesday, August 2, 2017

Proposed Changes to the Ratings of the Genitourinary System

On July 28th, 2017, the VA finally published a new section of proposed VASRD changes, this time to the ratings of the Genitourinary System. It has been almost a year since they published their last set of proposed changes to the ratings of the Skin.

The rewrite of the VASRD began in 2014 with the goal to be finished by the end of 2016. With significant delays, and many more sections left to go, there is no longer any clear timeframe as to when veterans can expect these changes to be finalized. So far, only the ratings for Mental Disorders have officially been updated. Although six other sections have been proposed so far, none of the proposed changes have yet been finalized and implemented.


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 8th, 2017. 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 Genitourinary 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 Urinary Rating Systems remain exactly the same. No changes proposed.
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All Urinary Conditions (codes 7512, 7515, 7516, 7517, 7518, and 7519) are all staying the same, except:

-Current- Code 7542: A Neurogenic Bladder occurs when a person loses control over urination because of damage to the nerves or the brain. This condition is rated on the Urinary Rating System.

-Proposed- Code 7542: A Neurogenic Bladder occurs when a person loses control over urination because of damage to the nerves or the brain. This condition is rated on either the Urinary Rating System or as a Urinary Tract Infection, whichever gives the higher rating.

The only change to this code is allowing it to be alternatively rated as a urinary tract infection. This is because neurogenic bladders have a high rate of urinary tract infections, so if that is the predominant disability and would offer a higher rating, that should be an alternative rating option.

-NEW Proposed Code- Code 7545: Diverticulum of the bladder occurs when the wall of the bladder weakens and a portion protrudes, creating a pouch. This causes urine to get trapped in the pouch, leading to voiding dysfunction and/or infection. It can be rated either on the Urinary Rating Systems or as a Urinary Tract Infection, whichever is the main disability.

The VA proposes to add this new code to cover diverticulum of the bladder. Currently, there aren’t any codes that truly reflect the disability of this condition. Thus it needs its own code.
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-Current- The ratings:

A 30% rating is given if the condition causes regular infections that require hospitalization 3 or more times a year, or if it requires serious continuous treatment.

A 10% rating is given if the condition requires regular drug therapy, 1 or 2 hospitalizations a year, or if it requires serious continuous treatment.

If any of these conditions that are rated as urinary tract infections also cause renal problems, then only one or the other can be rated. If the renal problems are more severe, then the condition should be rated under the renal rating system.


-Proposed- The ratings:

A 30% rating is given if the condition causes regular infections that require a stent or nephrostomy tube to be implanted for drainage, if the condition requires hospitalization 3 or more times a year, or if it requires serious continuous treatment.

A 10% rating is given if the condition requires suppressive drug therapy for 6 months or more, or 1 or 2 hospitalizations a year.

A 0% rating is given if the condition is recurrent and requires treatment of suppressive drug therapy for less than 6 months or antibiotic therapy, and does not require hospitalizations.

If any condition rated as a urinary tract infection also causes renal problems, then only one or the other can be rated unless they are diagnosably separate with clearly separate symptoms. If the renal problems are more severe, then the condition should be rated under the renal rating system.

The changes to the 30% simply specify that the infection must require drainage by more than a catheter in order to be rated at this level. Catheter drainage does not require surgery and rarely requires significant hospitalization.

The changes to the 10% more clearly define the required treatment. The VA argues that suppressive drug therapy for at least 6 months suggests a significant chronic condition appropriate for this rating level.

A 0% rating was added to enforce that anything less than the requirements for the 10% should be given a 0%.
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Conditions Rated As Urinary Tract Infections

Code 7501 for abscess of the kidney remains the same.

-Current- Code 7525: Chronic Epididymo-orchitis is pain in the epididymis. If the pain is caused by tuberculosis, it is rated as nonpulmonary tuberculosis.

-Proposed- Code 7525: The following chronic infections are all rated under this code: epididymitis (infection/inflammation of the epididymis), prostatitis (infection/inflammation of the prostate gland, urethritis (infection/inflammation of the urethra), and orchitis (infection/inflammation of the testicles—one or both).  If the condition is caused by tuberculosis, it is rated as nonpulmonary tuberculosis.

-Current- Code 7527: Prostate Gland conditions (any) are either rated as urinary tract infections or by the urinary rating system, whichever better defines the symptoms of the condition.

-Proposed- Code 7527: Prostate Gland conditions (all except prostatitis) and bladder outlet obstruction are rated under this code either as urinary tract infections or under the urinary rating system, whichever better defines the symptoms of the condition.

The VA recognized that there were quite a few infections that were not technically covered under the current codes, and so decided to add them in order to avoid improper analogous ratings. Thus, now code 7525 covers four conditions instead of just epididymitis. All of these conditions should have been rated under this code anyway, since they cause similar symptoms, but now it is official. No change in how they are rated.

For code 7527, they decided to move prostatitis to 7525 because it is closer to the other infections covered by that code. All other prostate conditions are still covered under this code. The VA also decided to add bladder outlet obstruction because it is often caused by a prostate condition and can produce similar symptoms. Thus, it needs the option to be rated as a urinary tract infection as well.

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-Current- A 100% rating is given if at least one of the following is present:
– The condition requires regular dialysis.
– The body cannot perform any physical activity because of persistent edema or because of albuminuria.
– A BUN of more than 80 mg/dL.
– A creatinine level of 9 mg/dL or more in the blood.
– A severely decreased functioning of the kidneys or other organs due to kidney dysfunction.
An 80% rating is given if one or more of the following is present:
– Persistent edema and albuminuria with a BUN of 40 to 80 mg/dL.
– A creatinine level of 4 to 8 mg/dL in the blood.
– Overall poor health with symptoms like lethargy, weakness, anorexia, weight loss, or the inability to exert much energy.
A 60% rating is given if one or more of the following is present:
– Constant albuminuria with some edema.
– A definite decrease in kidney function.
– Hypertension with the average diastolic pressure (the smaller number on the bottom in the blood pressure reading) of 120 or more.
A 30% rating is given if one or more of the following is present:
– Hypertension with the average diastolic pressure (the smaller number on the bottom) of 100 or more, or with the average systolic pressure (the larger number on top) of 160 or more.
– Albumin is present in the urine with either hyaline and granular casts or red blood cells.
A 0% rating is given if:
– Hypertension with the average diastolic pressure of less than 100, or with the average systolic pressure of less than 160.
– Albumin and casts are present in the urine with a history of nephritis.

-Proposed- To qualify for the following ratings, there must be a chronic kidney disease present.
            A 100% rating is given if at least one of the following is present:
– A GFR (glomerular filtration rate) less than 16mL/min
– The condition requires regular dialysis.
– Requires a kidney transplant (has not yet received one)
An 80% rating is given if the GFR is between 16 and 29 mL/min.
A 60% rating is given if the GFR is between 30 and 59 mL/min.
A 30% rating is given if the GFR is 60 mL/min or more AND at least one of
the following is present:
– The albumin/creatinine ratio (ACR) is 2.5g/gm or more (nephrotic range proteinuria)
– There is hypertension that qualifies for at least a 10% rating under code 7101
A 0% rating is given if the GFR is 60 mL/min or more AND at least one of
the following is present:
– The albumin/creatinine ratio (ACR) is between 0.03 and 2.49 g/gm
– There is hypertension that only qualifies for a 0% rating under code 7101
Note: Both estimated GFR (eGFR) and creatinine based approximations of GFR will be accepted for GFR ratings as long as they are calculated by a qualified physician.

These are by far the biggest changes proposed. The VA feels that the current renal ratings are based on out-dated medical tests and other vague standards. The glomerular filtration rate is now the medical standard used to measure how well kidneys are filtering the blood. As it is a more accurate test of kidney health, the VA proposes to use it as the standard for rating criteria.

The VA recognizes that the additional rating criteria is necessary to ensure that the full picture of the disease is taken into account for rating purposes. This is especially important for the 30% and 0% ratings, as a high GFR may not mean that the kidney isn’t impaired and causing symptoms. Thus both hypertension and the ACR are taken into account at these levels.

The 100% rating for individuals on the kidney transplant list is another important addition. Do note, however, that this is only for the time when they are waiting for the transplant. Once the transplant occurs (and the rehab period is over), the rating will be based on the functioning of the new kidney.
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The following conditions will still be rated on the renal rating system, but the new system proposed above.

Code 7500 for nephrectomy remains the same.

Code 7502 for nephritis remains the same, except that the note stating that only nephritis or a heart disease caused by the same condition (note both) could be rated is now extended to ALL renal conditions. So…

NEW NOTE FOR ALL RENAL CONDITIONS:

Renal disease is often closely related to heart disease. If renal disease is present and a heart disease is present and both are caused by the same general condition, then only one rating can be given even though there are two organs affected by the condition. Only the condition that rates the highest is used. The heart disease can, however, be rated separately if one kidney was removed because of renal disease but the remaining kidney is healthy. Then the heart disease warrants its own rating and the removed kidney can receive its own rating under code 7500. The heart disease could also be rated separately if the renal disease is severe enough to need regular dialysis.

All renal conditions are often closely related to heart conditions, so to limit this rule to just cases of nephritis doesn’t make sense. If the heart condition is caused by the same thing as the renal condition, then it applies.

Code 7504 for pyelonephritis remains the same.

Code 7507 for nephrosclerosis remains the same.

Code 7530 for any kidney disease that requires regular dialysis remains the same.

Code 7531 for a kidney transplant remains the same.

Code 7532 for renal tubular conditions remains the same.

-Current- Code 7533: Any cystic disease of the kidney is rated under this code. A cyst is a sac most often containing fluid that can grow anywhere in the body. Many do not cause problems, but some can seriously affect the functioning of the organs.


-Proposed- Code 7533: Any cystic disease of the kidney is rated under this code. A cyst is a sac most often containing fluid that can grow anywhere in the body. Many do not cause problems, but some can seriously affect the functioning of the organs. Some conditions rated under this code include poycystic diseases, uremic medullary cystic disease, medullary sponge kidney, hereditary nephritis, Alport’s syndrome, cystinosis, primary oxalosis, Fabry’s disease, and more.

Again, the VA is just adding more conditions to this code to make sure that they are rated under the most appropriate code.

-Current- Code 7534Atherosclerotic renal disease (also known as renal artery stenosis or atheroembolic renal disease) is a condition where the artery to the kidney narrows and decreases the blood flow to the kidney.

-Proposed- Code 7534Atherosclerotic renal disease (also known as renal artery stenosisatheroembolic renal disease, or large vessel disease) is a condition where the artery to the kidney narrows and decreases the blood flow to the kidney.

Similarly, the VA just wants to make sure that large vessel disease is properly rated under this code.

Code 7535 for toxic nephropathy remains the same.

Code 7536 for glomerulonephritis remains the same.

-Current- Code 7537: Interstitial nephritis occurs when the spaces between the tubules in the kidney swell. This reduces the ability of the kidneys to filter blood.

-Proposed- Code 7537: Interstitial nephritis occurs when the spaces between the tubules in the kidney swell. This reduces the ability of the kidneys to filter blood. This code also covers gouty nephropathy (the decrease of kidney function caused by high levels of uric acid due to gout) and disorders of calcium metabolism (the inability to properly metabolize calcium).

The VA feels that code 7537 is the best rating option for gouty nephropathy and disorders of calcium metabolism and so adds them here.

Code 7538 for papillary necrosis remains the same.

-Current- Code 7539Renal amyloid disease is caused by the buildup of protein in the kidney, which may result in the kidney not being able to filter blood.

-Current- Code 7541Renal Involvement in other conditions. So, if the kidneys are affected by conditions like sickle cell anemia, lupus, or diabetes, it can be rated separately from those conditions.


-Proposed- Code 7539Renal amyloid disease is caused by the buildup of protein in the kidney, which may result in the kidney not being able to filter blood.

In addition, renal involvement in other systemic conditions is rated under this code. This includes renal involvement in conditions such as lupus, sickle cell anemia, vasculitis, Henoch-Schonlein syndrome, and other systemic conditions.

-Proposed- Code 7541Renal involvement in diabetes mellitus is rated under this code. So if a veteran is diagnosed with either type I or type II diabetes, and it causes a decrease in renal function, it would be rated under this code.

For these two codes, the VA basically combined them all under code 7539. They only left diabetes mellitus separate because they wanted to be able to more accurately track the rate of this condition in the veteran population. Thus code 7541 is now just for renal involvement in diabetes.

-NEW Proposed Code- Code 7544: Renal disease caused by viral infections, such as HIV and Hepatitis B or C, are rated under this code. This code includes renal disease caused by the treatment of such viral infections as well.

The VA proposes to add a new code to specifically cover diseases caused by viral infections. While this code is not limited to HIV and Hepatitis B or C, for other viral infections to qualify, there must be regular clinical proof that the infection itself or its treatment causes kidney disease. For this reason, Hepatitis A is not included as there is clinical proof that it does not cause kidney disease.

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Code 7509 for hydronephrosis remains exactly the same.
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-Current- Code 7508: Nephrolithiasis (also known as kidney stones) is the presence of stones in the kidney or ureter. These stones block the flow of urine through the tubes. This condition is rated as hydronephrosis unless stones are repeatedly formed and it requires either drug therapy, diet therapy, or removal surgeries or procedures 3 or more times each year. If this is the case, it is rated 30%. Otherwise, rate as hydronephrosis.

-Current- Code 7510: Ureterolithiasis is the presence of stones in the ureter. These stones can block the flow of urine through the tubes. This condition is rated as hydronephrosis unless stones are repeatedly formed and it requires either drug therapy, diet therapy, or removal surgeries or procedures 3 or more times each year. If this is the case, it is rated 30%. Otherwise, rate as hydronephrosis.

-Proposed- Code 7508: Nephrolithiasis (also known as kidney stones) is the presence of stones in the kidney. Ureterolithiasis is the presence of stones in the ureter. Nephrocalcinosis is the buildup of calcium in the kidneys that can lead to stone formation. These stones block the flow of urine through the tubes.

If stones are repeatedly formed and it requires removal surgeries or procedures 3 or more times each year, it is rated 30%. Otherwise, rate as hydronephrosis.

The VA proposes combining codes 7508 and 7510 into a single code since both deal with the formation of stones that block the urinary tract. They also suggest adding nephrocalcinosis to this code to ensure its proper rating. The ratings for this would mostly stay the same, but dietary and drug treatments for stones have not proven pertinent to this condition, so they suggest removing them.

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Code 7511 for ureteral stricture remains exactly the same.
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-Current- Code 7520: If half or more of the penis is removed, then it is rated 30%. This condition can also be rated under the urinary rating system if that can result in a higher rating than 30%.

-Current- Code 7521: If the glans is removed, it is rated 20%. This condition can also be rated under the urinary rating system if that can result in a higher rating than 20%.

-Proposed- Code 7520: If half or more of the penis is removed, then it is rated 30%. This condition may qualify for SMC-K as loss of use of a creative organ.

-Proposed- Code 7521: If the glans is removed, it is rated 20%. This condition may qualify for SMC-K as loss of use of a creative organ.

The VA proposes to remove the option to rate these conditions as urinary dysfunction since most of the circumstances around urinary dysfunction (like leakage, use of a pad, etc.) don’t really apply. These both, however, might qualify for Special Monthly Compensation, Category K (SMC-K) since they may result in the loss of use of the creative organ, if it no longer can function in that way.
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-Current- Code 7522: If the penis is deformed and cannot erect, then it is rated 20%.

-Proposed- Code 7522: Erectile dysfunction, for any reason, is rated 0%. This condition may qualify for SMC-K as loss of use of a creative organ.

This is the change that is going to cause the most waves. The VA proposes to no longer rate erectile dysfunction at all. They justify this change by claiming that they offer compensable ratings for conditions that interfere with the veteran’s ability to work. Erectile dysfunction does not interfere with the veteran’s ability to work, and so should not be rated more than 0%.

They also add a note stating that Peyronie’s Disease is not a ratable condition and cannot be rated under code 7522.

This condition may, however, still qualify for Special Monthly Compensation, Category K (SMC-K) since it is considered loss of use of a reproductive organ.
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Code 7505 for tuberculosis of the kidney remains exactly the same.

Code 7523 for atrophy of the testicles remains exactly the same.

Code 7524 for removal of the testicles remains exactly the same.

Code 7528 for malignant cancer remains exactly the same.

Code 7529 for benign tumors remains exactly the same.

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-NEW Proposed Code- Code 7543: Varicocele (enlarged veins in the scrotum) and hydrocele (the build-up of fluid around the testicles) are both rated 0% under this code. These conditions may qualify for SMC-K as loss of use of a creative organ if they result in infertility.

The VA proposes adding a new code to cover varicocele and hydrocele—both conditions that are not currently addressed in the VASRD. These conditions do not interfere with the ability of the veteran to work, and so the VA proposes only a 0% rating. However, if they lead to infertility, they would qualify for SMC-K.
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1 comment:

  1. I had bladder cancer and it was remove and now have a stoma.
    What is the rating for this

    ReplyDelete