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Monday, August 7, 2017

Proposed Changes to the Ratings of the Musculoskeletal System

Again, in only a matter of days, the VA published a second section of proposed VASRD changes—after almost a year break—apparently trying to make up for lost time. On August 1st, the proposed changes to the ratings of the Musculoskeletal System were made public.

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, although if they continue releasing changes at this rate, it won’t be much longer.

So far, only the ratings for Mental Disorders have officially been updated, although the VA just published the final ruling for the changes to Dental and Oral Conditions a few days ago. We’ll have info regarding those coming up soon. Those changes will go into effect in September.  


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 20th, 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 Musculoskeletal System. The Musculoskeletal System is so vast, that we’ve broken it down into multiple pages on our site. Use the links below to find our discussions of the current ratings for these conditions.

            Amputations                           The Elbow and Forearm
            The Skull                                The Wrist
            The Spine                               The Hand
            The Ribs                                 The Hip and Thigh
            The Shoulder and Arm           The Knee and Leg
            The Ankle                               Diseases of the Musculoskeletal System
            The Foot                                 Cancer of the Musculoskeletal System
            Torso and Neck Muscles        Shoulder and Upper Arm Muscles
            Facial Muscles                        Buttock, Hip, and Thigh Muscles
            Muscle Hernias                       Forearm and Hand Muscles
            Foot and Lower Leg Muscles

The changes are fairly extensive, so I’ll walk through each, one at a time. If you don’t want to have to plod through them all, it might be most effective to just search for keywords (command-F works great!).

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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Code 5000 for osteomyelitis remains exactly the same.
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Code 5001 for tuberculosis of the musculoskeletal system remains exactly the same.
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-Current- Code 5002: Rheumatoid arthritis is the destruction of the soft tissues in a joint because of swelling. 

Regardless of how many joints are affected, if the arthritis is severe enough that you cannot function, but are completely incapacitated and bedridden, then it is rated 100%. 

If there is significant weight loss, anemia, and overall severe decrease in health but not complete incapacitation, or if severe incapacitating episodes happen 4 or more times a year, then it is rated 60%. 

If there is a definite decline in overall health, or if incapacitating episodes happen 3 or more times a year, then it is rated 40%. 

One or two episodes a year rates 20%.

These ratings cannot be used in addition to ratings for limited motion. One or the other. Any rheumatoid arthritis less severe than noted above is just rated upon its symptoms, such as limited motion. In these cases individual joints can be rated. So, if three joints are involved, but there are no incapacitating episodes, all three can be rated separately on limited motion. A minimum of 10% is given for every joint that at least has pain with motion.

-Proposed- Code 5002Multi-joint systemic arthritis includes any arthritis diseases (including rheumatoid arthritis, psoriatic arthritis, etc.) that affect multiple joints in the body and could affect other body systems as well. To be rated under this code, there must be a definite diagnosis, the arthritis must be active, and at least 2 joints must be affected. This code does not cover post-traumatic arthritis or gout.

If the arthritis is severe enough that you cannot function, but are completely incapacitated and bedridden, then it is rated 100%. 

If there is significant weight loss, anemia, and overall severe decrease in health but not complete incapacitation, or if severe incapacitating episodes happen 4 or more times a year, then it is rated 60%. 

If there is a definite decline in overall health, or if incapacitating episodes happen 3 or more times a year, then it is rated 40%. 

One or two episodes a year rates 20%.

Any arthritis no longer active or less severe than noted above is rated under code 5003 as degenerative arthritis. Multiple ratings, however, cannot be given. Any rating under this code cannot be combined with ratings for degenerative arthritis or limited motion in the same joints. Instead, the code that can offer the higher rating is used.

Although the ratings themselves did not change, the VA wanted to expand this code to cover all systemic arthritis, not just rheumatoid arthritis. The only other significant change was to rate lesser conditions as degenerative arthritis instead of just on limited motion.
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The only change for Code 5003 for degenerative arthritis is to adjust the name of the code to specify that this is for all degenerative arthritis except post-traumatic degenerative arthritis. The ratings remain exactly the same.
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Codes 5004-5008 for gonorrheal arthritis, pneumococcic arthritis, typhoid arthritis, syphilitic arthritis, and streptococcic arthritis, continue to be rated under code 5002 for any active disease and code 5003 for anything that doesn’t qualify for those ratings.
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-Current- Code 5009: All other arthritis is rated under this code.

-Proposed- Code 5009: All other diseases of the joints (except gout) are rated under this code. All active diseases are rated under code 5002, systemic arthritis. Anything that doesn’t qualify for a rating under that code is rated under code 5003, for degenerative arthritis.

The VA adjusted this code to include any other disease that would affect the joints, not just arthritis.
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-Current- Code 5010Post-traumatic arthritis is arthritis that is due to an accident or injury. This code doesn’t have its own ratings, but is rated as degenerative arthritis. The final code for this condition will look like this: 5010-5003. The first four-digit code defines the condition as traumatic arthritis, and the second four-digit code tells how it is rated.

-Proposed- Code 5010Post-traumatic arthritis is arthritis caused by an accident or injury. This condition is rated as limited motion, dislocation, or instability of the joint affected, whichever one is ratable for that joint and gives the higher rating. Multiple ratings for a single joint cannot be combined unless the codes specifically state that they can (as is the case for instability of the knee). Each joint receives its own rating.

Degenerative arthritis is just rated on limited motion of the joint, so the changes to this code allow instability and dislocation to be considered as a legitimate rating option instead of just limited motion.
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-Current- Code 5011Caisson disease is the premature death of bone and marrow cells, often caused by compressed air most often seen in divers. It is rated based on its most prevalent symptom. For example, if it affects the spinal cord and causes limited motion in the hip, it would be rated under that symptom. Common symptoms include deafness, arthritis in the joints, loss of motion, etc. Only the symptom that can give the highest rating can be rated for this condition. The final code for this condition would look like this: 5011-5261. The first four-digit code identifies the condition as caisson disease, and the second four-digit code tells what symptom the condition is rated under.

-Proposed- Code 5011Decompression sickness (a.k.a. caisson disease, divers’ disease, or the bends) occurs when gas bubbles form in the body because of decompression. The most common symptom is joint pain, however, since the bubbles can form in any part of the body, a variety of symptoms can occur, including arthritis, nerve and/or brain damage, hearing loss, skin damage, lung damage, and more. This condition is rated on its symptoms. So if it causes a rash on the skin and joint pain, it would be rated under arthritis and dermatitis. Each symptom receives its own rating as long as a single symptom is not rated twice (see the Pyramiding Principle).

The VA intends to expand this code to include any symptom caused by decompression sickness, not just ones related to the musculoskeletal system.
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Code 5012 for malignant bone cancer essentially remains the same. They updated some wording to modern medical jargon, but it has no effect on interpretation or rating. 
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Both code 5013, for osteoporosis, and code 5014, for osteomalacia, are basically remaining the same. The VA simply added “residuals of” to the requirements to show that the conditions themselves aren’t ratable—it’s the symptoms that they cause in the joints that are ratable. Ultimately, nothing really changes. This principle was already basically accepted and applied in ratings, they just wanted to make it super clear.
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Code 5015 for non-cancerous bone growth (“neoplasms”) remains the same.
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Codes 5016, 5019, and 5021 for osteitis deformans, bursitis, and myositis remain the same.
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Code 5017 for gout is currently rated under code 5002, rheumatoid arthritis. Under the proposed changes, it says that it should be rated under code 5003, which is the code for degenerative arthritis. We believe that this is a typo on the VA’s part, as they do not comment on such a large change, and in fact, state that no real change occurred to this code. We believe that it will continue to be rated under code 5002.
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The VA proposes to remove the following codes:

-Current- Code 5018: Intermittent hydrarthrosis is the periodic swelling most commonly of major joints, although other joints could also be affected, on a regular and predictable schedule.

-Current- Code 5020: Synovitis is the swelling of a membrane that lines synovial joints.

-Current- Code 5022Periostitis is the swelling of the tissue that surrounds the bones.

Based on modern medical practices, these conditions are actually symptoms of larger conditions, like rheumatoid arthritis, and so should not be treated as stand-alone conditions. Instead, any disability they cause is already covered by the rating of the main condition.
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Codes 5023 for myositis ossificans remains the same, but the name is changed to heterotopic ossification. This is the term for this condition that is currently the accepted norm.
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The name for code 5024 is changed to include not only tenosynovitis, but also tendinitis, tendinosis, and tendinopathy. All of these conditions should already be rated under this code, but this makes it more clear exactly where these conditions are intended to be rated.
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Code 5025 for fibromyalgia remains the same.
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Prosthetic Implants and Resurfacing

For all codes 5051-5056 for the prosthetic replacement of joints and resurfacing, a note is added that specifies that no other musculoskeletal rating can be given in addition to this code. Separate ratings can be given for nerve conditions or scars caused by these procedures, but not for arthritis, limited motion, etc. Only one musculoskeletal rating per condition.

Besides the above note, codes 5051-5053 and 5056 for shoulder, elbow, wrist, and ankle replacements remain the same.

-Current- Code 5054: If either the entire head of the femur or entire head of the acetabulum has been replaced by a false joint prosthesis, then the condition is rated 100% for the first year after the surgery. (This period is mainly for the VA, but the DoD will also use it if the veteran is placed on TDRL before being permanently separated). After the 1-year period, the condition is given a permanent rating. If there is weakness and severe pain with motion that requires the use of crutches, then it is rated 90%. If there is weakness and severe pain, but it does not require crutches, then it is rated 70%. If the pain is not severe, but does limit the range of motion, then it is rated 50%. The minimum rating for a hip replacement is 30%. 

If your condition rates 90% under this code, you may also qualify for additional compensation by the VA. Please see the Special Monthly Compensation page for more information.

-Proposed- Code 5054: If the hip has been resurfaced or if either the entire head of the femur or entire head of the acetabulum has been replaced by a false joint prosthesis, then the condition is rated 100% for the first 4 months after the surgery. (This period is mainly for the VA, but the DoD will also use it if the veteran is placed on TDRL before being permanently separated). After the 4-month period, the condition is given a permanent rating.

For joint replacements: If there is weakness and severe pain with motion that requires the use of crutches, then it is rated 90%. If there is weakness and severe pain, but it does not require crutches, then it is rated 70%. If the pain is not severe, but does limit the range of motion, then it is rated 50%. The minimum rating for a hip replacement is 30%. 

If your condition rates 90% under this code, you may also qualify for additional compensation by the VA. Please see the Special Monthly Compensation page for more information.

For resurfacing: All remaining symptoms are rated as limited motion of the hip, too much motion or dislocation of the hip, no motion (frozen joint) of the hip, or issues with the hip bones. The code that best describes the overall symptoms and provides the highest rating is assigned.

-Current- Code 5055: If the entire knee joint has been replaced by a prosthesis, then the condition is rated 100% for the first year after the surgery. (This period is mainly for the VA, but the DoD will also use it if the veteran is placed on TDRL before being permanently separated). After the 1-year period, the condition is given a permanent rating. If there is weakness and severe pain with motion, then it is rated 60%. If the pain is not severe, but does limit the range of motion, then it is rated under code 5256 if it is frozen, or under codes 5261 or 5262, discussed below, if it is not frozen. The minimum rating for a total knee replacement, however, is 30% regardless of how much motion it has.

Note: This code is only for total knee replacements. Partial replacements are rated on any symptoms that they cause, like limited motion.

-Proposed- Code 5055: If the knee has been resurfaced or If the entire knee joint has been replaced by a prosthesis, then the condition is rated 100% for the first 4 months after the surgery. (This period is mainly for the VA, but the DoD will also use it if the veteran is placed on TDRL before being permanently separated). After the 4-month period, the condition is given a permanent rating.

For replacements: If there is weakness and severe pain with motion, then it is rated 60%. If the pain is not severe, but does limit the range of motion, then it is rated under code 5256 if it is frozen, or under codes 5261 or 5262, discussed below, if it is not frozen. The minimum rating for a total knee replacement, however, is 30% regardless of how much motion it has.

Note: This code is only for total knee replacements. Partial replacements are rated on any symptoms that they cause, like limited motion.

For resurfacing: All remaining symptoms are rated as limited motion of the knee, too much motion or instability of the knee, no motion (frozen joint) of the knee, cartilage removal or dislocation, or issues with the lower leg bones. The code that best describes the overall symptoms and provides the highest rating is assigned.

Joint resurfacing is now a common alternative for joint replacements for the hip and the knee.  While they provide similar disability as a joint replacement, they do not qualify under the current rating requirements. Thus the VA proposes to adjust code 5054 and 5055 to include resurfacing. Resurfacing, however, creates a shorter convalescent period and fewer long-term disabilities. Thus, they propose only a 4 month 100% rating period and then alternative rating options for remaining symptoms after the resurfacing.
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Code 5104, 5105, and 5108 for hand and foot combination amputation/loss of use remains the same.
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Code 5106 for both hand amputation remains the same.
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Code 5107 for both foot amputation remains the same.
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Code 5109 for loss of use of both hands remains the same.
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Code 5110 for loss of use of both feet remains the same.
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Code 5111 for loss of use of one hand and one foot remains the same.
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-Current- Code 5120: If the entire arm is amputated from the shoulder joint down, it is rated 90% for either arm.

-Proposed- Code 5120: If the entire arm is amputated from the top of the humerus down, it is rated 90% for either arm. If the amputation includes the shoulder, including the scapula, clavicle, and/or ribs, it is rated 100% for either arm.

The VA proposes adding a 100% rating option for amputees with more than just the shoulder joint and arm removed. The further removal of ribs and the shoulder results in a higher level of disability as prosthetics are much more difficult, if not impossible, to use.
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Codes 5121-5156 for various amputations of the arms, hands, and fingers remain the same.
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-Current- Code 5160: If the entire leg is amputated at the hip joint, it is rated 90%.


-Proposed- Code 5160: If the entire hip is amputated from the top of the femur down, it is rated 90%. If the amputation includes any part of the pelvic bones as well, it is rated 100%.

If the amputation causes any bladder or bowel problems, they can be rated separately.

The VA proposes adding a 100% rating option for amputees with more than just the hip joint and leg removed. The further removal of the pelvis results in a higher level of disability as prosthetics are much more difficult, if not impossible, to use.
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Codes 5161-5167 and 5171-5173 for various amputations of the legs, feet, and toes remain the same.
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-Current- Code 5170: If all of the toes are amputated, not including the ball of the foot, it is rated 30%.

-Proposed- Code 5170: If all of the toes are amputated, not including the ball of the foot, it is rated 30%. This can include up to half of the metatarsals, but less than the entire ball of the foot.

The VA wants to clarify that anything more than all of the toes but less than the ball of the foot should be rated under this code.
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Code 5200 for a frozen shoulder joint remains the same.
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The VA changed some of the phrasing in code 5201 for limitation of motion of the shoulder, but it effectively remains exactly the same.
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Code 5202 for dislocation of the humerus and other humerus bone conditions effectively remains the same.
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Codes 5203-5213 for all other conditions of the shoulder and arm remain the same.
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Codes 5214-5215 for conditions of the wrist remain the same.
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Codes 5216-5230 for conditions of the hand remain the same.
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Codes 5235-5241 for conditions of the spine remain the same.
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Code 5242 for degenerative arthritis of the spine is further expanded to include degenerative disc disease and all other disc conditions (except intervertebral disc syndrome). The ratings remain the same.
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Code 5243 for intervertebral disc syndrome remains the same.
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-NEW Proposed- Code 5244: Both paraplegia and quadriplegia are rated under this code. Paraplegia is the complete paralysis of the legs and lower body. It is rated 100% under code 5110, complete loss of use of the feet. This condition is also entitled to Special Monthly Compensation.

Quadriplegia is the complete paralysis of both the arms and the legs. It is given two ratings: 100% under code 5110 for complete loss of use of the feet, and 100% under code 5109 for complete loss of use of the hands. Having two 100% ratings qualifies the veteran for a higher level of Special Monthly Compensation.
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Codes 5250-5254 for limited motion of the hip, no motion of the hip, and too much motion of the hip remain the same.
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-Current- Code 5255: Any problems with the femur or femoral neck bones are rated under this code. If either is completely broken through and it causes loose or erratic leg motion, then it is rated 80%. If it is broken through but the leg motion is not loose and the leg can support weight with the help of a brace, then it is rated 60%. If it is fractured and has a false joint, it is rated 60%. 

All other femur bone conditions are rated by how they affect the hip or knee joint. If they cause serious problems (can barely use the joint at all), then it is a 30% rating. If the joints can be used, but the condition significantly limits the amount of activity, then it is rated 20%. If the hip or knee joint is affected only slightly, then it is rated 10%.

-Proposed- Code 5255: Any problems with the femur or femoral neck bones are rated under this code. If either is completely broken through and it causes loose or erratic leg motion, then it is rated 80%. If it is broken through but the leg motion is not loose and the leg can support weight with the help of a brace, then it is rated 60%. If it is fractured and has a false joint, it is rated 60%. 

All other femur bone conditions are rated by how they affect the hip or knee joint, whichever results in a higher rating. Rating options for the knee include code 5256, code 5257, code 5260, or code 5261. Rating options for the hip include, codes 5250-5254. Only one code can be assigned for this condition.

The VA recognizes that the current language for these ratings is rather vague. It’s hard for “marked” to be regularly defined by every rating authority, etc. Because of this, ratings for femur bone conditions aren’t standard across the board. To fix this, the VA suggests rating it instead on exactly how the knee or hip are affected, thus eliminating guesswork.
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Code 5256 for no motion of the knee remains the same.
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-Current- Code 5257: The knee can have too much motion (instability) from side to side or dislocate regularly. This can happen when the tendons and cartilage are damaged and can no longer support the knee joint properly. If there is only slight instability, then it is rated 10%. If there is more instability that might cause the knee to buckle or dislocate every now and then, then it is rated 20%. If, however, it is so unstable that it gives out or dislocates regularly, it is rated 30%.

Code 5257: The knee can also have too much motion (instability) from side to side or dislocate (subluxation) regularly. This can happen when the tendons and cartilage are damaged and can no longer support the knee joint properly. Similarly injuries can cause the kneecap instability, causing it to shift out of position.

For general instability and subluxation:

If surgery was performed, there is still 11mm or more of abnormal joint motion, and a physician prescribed both a brace and a device to help with walking (crutch, walker, cane, etc.), it is rated 30%.

If surgery wasn’t performed, there is 11mm or more of abnormal joint motion, and a physician prescribed both a brace and a device to help with walking (crutch, walker, cane, etc.), it is rated 20%.

With any amount of abnormal motion, if a physician prescribes either a brace or a device to help with walking, it is rated 10%.

For kneecap instability:

If the kneecap continues to be unstable after surgery is performed, it is rated 30%. The surgery must have been done specifically to fix the instability. Surgery to remove bone fragments or other knee surgeries that do not address the instability do not qualify.

If surgery was not performed, but there is regular kneecap instability and there are one or more abnormalities in the knee (damage to the ligaments, bone flakes in the knee, breaks or other issues with the kneecap itself, damage to the femoral trochlea, etc.), it is rated 20%.

If surgery was not performed, there is regular kneecap instability, but there are no other abnormalities, it is rated 10%.

The VA proposes more measureable rating requirements for instability of the knee. Since “mild,” “moderate,” and “severe” are difficult to uniformly define, more specific criteria is needed to eliminate inconsistent ratings. They also propose adding ratings specific to kneecap instability. The kneecap is not sufficiently addressed at all under the current ratings.
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Code 5258-5261 for conditions of the meniscus and limited motion of the knee remains the same.
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-Current- Code 5262: Any problems with the tibia or fibula bones in the lower leg are rated under this code. If there is a complete break in either bone that cannot heal and requires a brace, then it is rated 40%. All other conditions are rated by how they affect the knee or ankle joint. If they cause serious problems (can barely use the joint at all), then it is a 30% rating. If the joints can be used, but the condition significantly limits the amount of activity, then it is rated 20%. If the knee or ankle joint is affected only slightly, then it is rated 10%.

-Proposed- Code 5262: Any problems with the tibia or fibula bones in the lower leg are rated under this code.

If there is a complete break in either bone that cannot heal and requires a brace to stabilize, then it is rated 40%. 

Medial tibial stress syndrome (a.k.a. “MTSS” or “shin splints”) must be officially diagnosed by x-ray, bone scan, or MRI in order to qualify for a compensable rating.

If both legs are affected, it has been treated consistently for 12 months or more, and it is not responsive to any form of treatment, it is rated 30%.

If only one leg is affected, it has been treated consistently for 12 months or more, and it is not responsive to any form of treatment, it is rated 20%.

If one or both legs are affected, it has been treated consistently for 12 months or more, and it is only unresponsive to conservative treatments (like orthotics), it is rated 10%.

If the condition has been treated for less than 12 months, it is rated 0%.

All other conditions (including malunion) are rated by how they affect the knee or ankle joint, whichever results in a higher rating. Rating options for the knee include code 5256, code 5257, code 5260, or code 5261. Rating options for the ankle include, codes 5270-5271. Only one code can be assigned for this condition.

Again, the VA is trying to get rid of vague language that leaves too much up to interpretation. Thus instead of rating other conditions on “moderate,” etc., they suggest rating them on the actual impairment of the joints affected. The proposed ratings also add separate rating criteria for shin splints, a condition previously ignored in the ratings.
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Code 5263 for genu recurvatum remains the same.
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All ankle ratings, except code 5271 (below), remain the same.
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-Current- Code 5271: If the ankle is not frozen, but limited in motion, then it is rated under this code. Normal range of motion for the ankle is 0° to 20° dorsiflexion and 0° to 45° plantar flexion. A 20% rating is given for a markedly limited range of motion and a 10% is given for a moderately limited range of motion.

-Proposed- Code 5271: If the ankle is not frozen, but limited in motion, then it is rated under this code. Normal range of motion for the ankle is 0° to 20° dorsiflexion and 0° to 45° plantar flexion.

If dorsiflexion is less than 5° or plantar flexion is less than 10°, it is rated 20%. If dorsiflexion is between 5° and 14° or plantar flexion is between 10° and 29°, it is rated 10%.

The VA proposes to get rid of the vague “marked” and “moderate” requirements and instead define the exact range of motions necessary for the ratings.
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Code 5275 for shortening of the bones remains the same.
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All current foot codes remain the same.
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-NEW Proposed- Code 5285: Plantar fasciitis is a condition where the skin and tissues on the bottom of the foot swell and cause pain. If both feet are affected, and the symptoms are not responsive to any kind of treatment, including surgery, it is rated 30%. If only one foot is affected, and the symptoms are not responsive to any kind of treatment, including surgery, it is rated 20%. If the symptoms are treatable, it is rated 10%.

If the condition is not responsive to treatment and is so severe that the foot cannot be used at all, it is rated 40% under code 5167 for loss of use of the foot.

The VA proposes to add this code because plantar fasciitis is a common enough condition that it should be given its own rating system.
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Codes 5296-5298 for skull conditions, rib conditions, and conditions of the coccyx remain the same.
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All codes for Muscle Ratings remain the same except for the addition of the following two new codes:

-NEW Proposed- Code 5330: Rhabdomyolysis is a condition where the muscles break down rapidly, usually due to trauma or overuse. Each muscle group affected is rated separately. So if a crush injury causes rhabdomyolysis in the forearm and hand, affecting all three of the muscle groups in that area, it will be given three separate ratings. 

Additionally, as the muscles break down and are absorbed into the blood, the kidneys can be damaged. Because of this, any kidney damage caused by rhabdomyolysis can be rated separately.

-NEW Proposed- Code 5331: Compartment Syndrome is a condition where pressure builds up rapidly in the tissues, usually due to a trauma or overuse, and cuts off the blood supply to an area of muscle. Each muscle group affected is rated separately. So if a crush injury causes compartment syndrome in the forearm and hand, affecting all three of the muscle groups in that area, it will be given three separate ratings.

The VA proposes to add these two new codes to help the rating authorities know how best to rate these conditions. Currently they are rated analogously on any muscle groups that are damaged, but these codes make the requirements more clear. Hopefully it will avoid improper ratings.
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