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Friday, February 8, 2019

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

On February 5th, 2019, the VA published a new section of proposed VASRD changes, this time to the ratings of Infectious Diseases, Immune Disorders, and Nutritional Deficiencies

The rewrite of the VASRD began in 2014 with the goal to be finished by the end of 2016. While they clearly haven’t met their goal, the VA continues to slowly release proposed and finalized changes. 

So far, finalized changes have been made to the ratings of the Skin, the Female Reproductive System, the Eyes, the Dental and Oral Conditions, the Endocrine System, and Mental Disorders.

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

With each set of proposed changes, the VA allows a period in which comments can be submitted. The VA then takes each comment into consideration and makes any additional changes that are warranted before publishing the final ruling. 

We encourage you to submit any comments you might have on these proposed changes to us either by commenting on this post or by contacting us through our website. All comments must be received by April 8th, 2019. We will then compile all of your comments into a single report and submit it on your behalf to the VA, just as we did for the other sections (see the Female Reproductive System Comments). This is a great opportunity to really make a difference, so please let us know your thoughts. 
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The following are the VA’s proposed changes to the ratings for Infectious Diseases, Immune Disorders, and Nutritional Deficiencies. The changes are fairly extensive, so I’ll walk through each, one at a time.

For each condition, the 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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-NEW Proposed- General Rating System for Infectious Diseases

A 100% rating is given for all active diseases. Once the infection is eliminated or completely suppressed, the condition must be re-evaluated and rated 0%. Any lasting side effects caused by the infection are then rated separately.  

The VA is proposing to create a General Rating System for Infectious Diseases. This doesn’t have a huge effect on the ratings as currently all infectious diseases are rated 100% while active, then on residual symptoms/conditions. Regardless, creating a central rating system like this will more greatly ensure consistency in applying the ratings to infectious diseases. 

The addition of a 0% rating for an inactive disease also doesn’t have any direct impact on the ratings themselves, but will allow for an easier adjustment to the ratings if the disease relapses.   
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-Current- Code 6300Asiatic cholera is an infection in the small intestine that causes severe diarrhea and vomiting. The 100% rating for this condition continues for 3 months after the active infection. If there are symptoms left over after the 3-month period, then they are rated separately. These symptoms could include papillary necrosis, which is rated under code 7538.

-Proposed- Code 6300:  Vibriosis (cholera and non-cholera) is an infection in the small intestine caused by Vibrio bacteria. It is rated on the General Rating System. Lasting side effects could include renal failure, skin conditions, and musculoskeletal conditions (like muscle damage, arthritis, etc.).  

Currently, this code only covers Asiatic cholera, which is caused by the Vibriobacteria. This bacteria, however, can cause many other types of infections as well. To ensure that those infections are properly recognized and rated, the VA proposes changing this code to include all Vibrioinfections. The other change to this code is to eliminate the 100% rating for the 3 months after the active infection since modern treatments allow full recovery in a fairly short time period. 
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-Current- Code 6301: Visceral leishmaniasis is a disease of parasites in the internal organs that can cause symptoms like weight loss, fever, and anemia. The 100% rating for this condition continues for the first 6 months after treatment for this disease ends. It is then reevaluated, and any remaining symptoms or side effects are rated separately. These symptoms could include liver damage, which is rated under code 7312.

-Proposed - Code 6301: Visceral leishmaniasis is a disease of parasites in the internal organs that can cause symptoms like weight loss, fever, and anemia. It is rated 100% while it is active. The 100% rating for this condition continues for the first 6 months after treatment for this disease is no longer active. It is then reevaluated, and any remaining side effects are rated separately. These side effects could include liver damage and bone marrow diseases.

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

The only changes to this code are to include bone marrow diseases in the list of potential residuals and to specify that any recurrence must be properly confirmed by lab test. 
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-Current- Code 6302: Leprosy (or “Hansen’s Disease”) is a bacterial disease that attacks the skin, nerves, and airways. It causes severe skin damage and can lead to many other conditions if left untreated. The 100% rating for this condition continues for the first 6 months after treatment for this disease ends. It is then reevaluated, and any remaining symptoms or side effects are rated separately. These symptoms could include skin damage, codes 7800–7805, or nerve damage. Nerve damage is a bit complicated to rate, and the code depends on which nerves are damaged. Thorough information on rating nerve damage can be found on The Central Nervous System page.


-Proposed - Code 6302: Leprosy (or “Hansen’s Disease”) is a bacterial disease that attacks the skin, nerves, and airways. It causes severe skin damage and can lead to many other conditions if left untreated. The 100% rating for this condition continues for the first 6 months after treatment for this disease ends. It is then re-evaluated, and any remaining side effects are rated separately. These side effectscould include skin damage, nerve damage, or amputation.

The VA proposes to add amputations to the list of possible residuals since leprosy can lead to auto-amputation.  
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-Current- Code 6304: Malaria is a disease of parasites that infect red blood cells and cause severe fevers and other symptoms. For malaria to be properly diagnosed, it must be confirmed by blood smear tests unless it is clear that the veteran was in an area where contamination could be very likely. The 100% rating for this condition continues only while the condition is active. Afterwards, any remaining side effects are rated separately. These symptoms could include liver damage, which is rated under code 7312.

-Proposed - Code 6304: Malaria is a disease of parasites that infect red blood cells and cause severe fevers and other symptoms. It is rated on the General Rating System. For malaria to be properly diagnosed (initially and for any recurrence), it must be confirmed by blood smear tests or lab tests, like antigen detection, immunologic tests, and molecular tests. Side effectscould include liver damage, spleen damage, and central nervous system conditions.

The VA is proposing to require proper tests to diagnose all cases of malaria before they can be rated. They also are adding a few potential symptoms to the list, though these lists are never exhaustive.  
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-Current- Code 6305: Lymphatic filariasis is a disease of parasites that infect the lymphatic system, including the lymph nodes. The 100% rating for this condition continues only while the condition is active. Afterwards, any remaining symptoms or side effects are rated separately. These symptoms could include epididymitis, which is rated under code 7525.

-Proposed - Code 6305: Lymphatic filariasis (“elephantiasis”) is a disease of parasites that infect the lymphatic system, including the lymph nodes. It is rated on the General Rating System. Side effectscould include epididymitis and various lymphatic conditions.

The only proposed change here is to include the name “elephantiasis” that is commonly used to refer to this condition and to include various lymphatic conditions in the list of side effects. 
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-Current- Code 6306: Bartonellosis is a bacterial infection which can cause many other diseases including trench fever, chronic bacteremia, endocarditis, neurological conditions, Carrion’s disease, cat-scratch disease, bacillary angiomatosis, peliosis hepatis, and chronic lymphadenopathy. All of these conditions are rated under this code. The 100% rating for this condition continues for three months after the condition is active. Afterwards, any remaining symptoms or side effects are rated separately. These symptoms could include skin damage, which is rated under codes 7800–7805.

-Proposed- Code 6306: Bartonellosis is a bacterial infection which can cause many other diseases including trench fever, chronic bacteremia, neurological conditions, Carrion’s disease, cat-scratch disease, bacillary angiomatosis, peliosis hepatis, and chronic lymphadenopathy. All of these conditions are rated under this code. 

It is rated on the General Rating System. Side effects could include skin damage and endocarditis.

Again, not a huge change. Removing the three-month rating since it is usually easily treated and including endocarditis as a potential side effect. 
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-Current- Code 6307: Plague (any kind) is a bacterial infection that can attack different parts of the body. It can be treated if caught early. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include gangrene that could lead to amputation. It would then be rated on the amputation of the particular body part. See the Amputations page for a complete list of amputation ratings. In addition to gangrene, this condition could also cause nerve or brain damage. The code depends on the extent of the nerve or brain damage. All nerve and brain conditions are discussed on The Central Nervous System page.

-Proposed- Code 6307: Plague (any kind) is a bacterial infection that can attack different parts of the body. It is rated on the General Rating System.

Treatments for the plague are advanced to the point that residuals or side effects are very rare. They can absolutely be rated if they occur, but the VA feels that they no longer need to be directly discussed. 
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-Current- Code 6308: Relapsing fever is a bacterial infection that causes fevers, chills, aches, and nausea that can last between 2 and 9 days. Every couple of weeks, these symptoms return if not treated with antibiotics. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include liver damage, code 7312, spleen damage, codes 7706-7707, or nerve damage. The code for nerve damage depends on which nerve is affected and the severity of the damage. Thorough information on rating nerve damage can be found on The Central Nervous System page.

-Proposed- Code 6308: Relapsing fever is a bacterial infection that causes fevers, chills, aches, and nausea that can last between 2 and 9 days. Every couple of weeks, these symptoms return if not treated with antibiotics. It is rated on the General Rating System. Side effects could include liver damage, spleen damage, choroidopathy, or nerve damage

The VA’s proposing to add choroidopathy (like iritis, uveitis, etc.) as a potential side effect.
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-Current- Code 6309: Rheumatic fever is a disease that affects the tissues of the body, causing them to swell. It can damage the valves of the heart, which can cause congestive heart failure. Symptoms also include rashes, twitching in the face and arms, and fevers. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include heart damage, code 7020.

-Proposed- Code 6309: Rheumatic fever is a disease that affects the tissues of the body, causing them to swell. It can damage the valves of the heart, which can cause congestive heart failure. Symptoms also include rashes, twitching in the face and arms, and fevers. It is rated on the General Rating System. Side effects could include heart damage, code 7020.

The only proposed change to this code is for it to be rated on the General Rating System. 
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Code 6310 for syphilis remains the same.
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-Current- Code 6311: Miliary tuberculosis is tuberculosis that began in the lungs but then traveled to other parts of the body. This condition would be rated for both pulmonary and nonpulmonary tuberculosis. (Their 100% ratings, however, cannot be combined during the 1-year period after inactivity. Their symptoms or complications, however, can be rated during that period instead of waiting for reevaluation at the 1-year mark).

-Proposed- Code 6311: Miliary tuberculosis is tuberculosis that began in the lungs but then traveled to other parts of the body. This condition is rated 100% while active. Once inactive, the 100% rating continues for one year, and any side effects not covered by this rating (things that would qualify the veteran for additional benefits, like SMC) can be rated as well. At the end of the 1-year period, the condition is re-evaluated, and any side effects, like skin conditions, respiratory conditions, eye conditions, digestive conditions, etc., can be rated separately. 

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

The ratings for this code haven’t actually changed at all, but the VA is hoping to create a clearer rating system by simplifying the language of this code instead of referring to other codes. 
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-Proposed NEW CODE- Code 6312:  Non-tuberculosis mycobacterial infection (“NTM”) is a lung infection, that isn’t tuberculosis, which occurs when bacteria is inhaled. This can cover a wide-range of infections caused by different types of inhaled bacteria. This condition is rated 100% while active. Once inactive, the condition is re-evaluated, and any side effects, like skin conditions, respiratory conditions, eye conditions, digestive conditions, etc., can be rated separately. 

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

The VA proposes to add this new code to cover all inhaled bacterial infections. Currently, tuberculosis is the only code similar enough to cover these infections, but tuberculosis presents differently and has more severe long-term implications than many of these other infections. As such, this code would enable a clearly distinct rating option for these conditions. 
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Code 6313 for Avitaminosis, code 6314 for Beriberi, and code 6315 for Pellagra will remain the same.
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-Current- Code 6316: Brucellosis is a bacterial infection that causes fevers, headaches, depression, and weakness. The symptoms can come and go throughout the rest of your life if the disease is not properly treated with antibiotics. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include liver damage, code 7312, or meningitis, code 8019.

-Proposed- Code 6316: Brucellosis is a bacterial infection that causes fevers, headaches, depression, and weakness. Diagnosis and any recurrence must be confirmed by culture and/or serologic testing. It is rated on the General Rating System. Side effects could include liver damage, meningitis, and spleen damage.

The VA proposes to require the appropriate tests to diagnose the condition in order to ensure both proper rating and proper treatment.  
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-Current- Code 6317: Scrub typhus is an infection caused by parasites that can be treated with antibiotics, although many strains are not responsive to treatments. The 100% rating for this condition continues while the condition is active and for the first 3 months following. After that, any remaining side effects or symptoms are rated separately. These symptoms could include skin damage, codes 7800–7805, and spleen damage, codes 7706-7707.

-Proposed- Code 6317:  Rickettsial infections (including scrub typhuserlichiosis, and anaplasmosisare rated under this codeThese diseases are all commonly passed from ticks, fleas, or other parasites. It is rated on the General Rating System. Side effects could include bone marrow conditions, skin conditions, central nervous conditions, and spleen damage.

The VA proposes to broaden the name of the code to include all conditions caused by rickettsial infections, not just scrub typhus. These conditions are already rated analogously under this code, but this change will make it easier to rate them. They are also proposing to remove the 3-month rating after the active infection since these infections are easily controlled by modern medicines. 
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-Current- Code 6318: Melioidosis is a bacterial infection that causes pain, coughing, pneumonia and skin infections. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include arthritis, code 5003, lung tissue damage, code 6825, or meningitis, code 8019.

-Proposed- Code 6318: Melioidosis is a bacterial infection that causes pain, coughing, pneumonia, and skin infections. Diagnosis and any recurrence must be confirmed by culture or appropriate lab testing. It is rated on the General Rating System. Side effects could include arthritis, meningitis, and lung lesions.

The VA proposes to require the appropriate tests to diagnose the condition in order to ensure both proper rating and proper treatment.  
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-Current- Code 6319: Lyme disease is a bacterial disease common in the US and spread by ticks. Symptoms include fever, skin rash, fatigue, and depression and can affect the joints, heart and nerves if it is not treated properly. The 100% rating for this condition continues only while the condition is active. After that, any remaining side effects or symptoms are rated separately. These symptoms could include arthritis, codes 5002-5003, heart damage, code 7020, chronic fatigue, code 6354, and nerve damage.

-Proposed- Code 6319: Lyme disease is a bacterial disease common in the US and spread by ticks. Symptoms include fever, skin rash, fatigue, and depression and can affect the joints, heart, and nerves if it is not treated properly. It is rated on the General Rating System. Side effects could include arthritis, Bell’s palsy, nerve damage, eye conditions, and mental dysfunction.

The only proposed change is to adjust the side effects list to include the most common side effects for this condition. 
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Code 6320 for other parasitic diseases will remain the same.
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-NEW Proposed Code- Code 6325: Hyperinfection syndrome (“disseminated strongyloidiasis”) is a parasitic disease caused by roundworms. Symptoms include severe infections, diarrhea, skin rash, and weight loss. It is rated 100% while active. Once it is inactive, it is re-evaluated and rated on any remaining side effects. 

The VA proposes adding a new code for hyperinfection syndrome, a condition that presents unique symptoms and causes an incredibly severe infection with a high mortality rate and vast, significant side effects. 
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-NEW Proposed Code- Code 6326: Shistosomiasis (“Katayama syndrome”) is an extremely common parasitic disease outside of the US. Symptoms include skin rash, fever, and headaches. This condition is usually mild in most people, but some can have negative reactions to the parasite eggs that can cause long-term side effects. Since the active infection itself is mild, it is rated 0%. However, in cases that cause side effects, like liver damage, digestive conditions, genitourinary conditions, female reproductive conditions, or central nervous conditions, they can be rated separately. 

The VA proposes adding a new code for shistosomiasis, a unique condition that is usually mild but can have significant disabling effects in some veterans. This code would allow those veterans affected to be properly rated. 
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-NEW Proposed Code- Code 6329: Hemorrhagic fevers (including dengue feveryellow fever, etc.) are fevers caused by a viral infection. It is rated on the General Rating System. Side effects could include liver damage, kidney damage, and central nervous conditions.  

The VA proposes adding this new code to avoid having to rate these fevers analogously.  
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-NEW Proposed Code- Code 6330: Campylobacter jejuni is the most common type of food poisoning. Symptoms include diarrhea, nausea, and fever. It is rated on the General Rating System. Side effects could include uveitis, Guillain-Barre syndrome, and reactive arthritis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6331: Coxiella burnetii infection (“Q fever”) is a bacterial infection spread by animals which causes flu-like symptoms. It is rated on the General Rating System. Side effects could include chronic hepatitis, chronic fatigue syndrome, and osteomyelitis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6333: Salmonella infections (non-typhoid) is the most common type of food poisoning. Symptoms include diarrhea, nausea, and fever. It is rated on the General Rating System. Side effects could include reactive arthritis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6334: Shigella infections (including dysenteryare the most common cause of diarrhea. It is rated on the General Rating System. Side effects could include hemolytic-uremic syndrome and reactive arthritis.  

The VA proposes adding this new code to avoid having to rate it analogously.  
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-NEW Proposed Code- Code 6335: West Nile virus infections are spread by mosquitoes. Symptoms include headache, vomiting, and fever. It is rated on the General Rating System. 

The VA proposes adding this new code to avoid having to rate it analogously.  
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Code 6350 for lupus erythematosus will remain the same.
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-Current- Code 6351: HIV (human immunodeficiency virus) is a virus mostly spread by sexual contact with an infected person, although it can also be spread from mother to child or by contact with infected blood. The virus attacks “T4” cells that support the immune system of the body, thus causing the body to be very vulnerable to infections, other diseases (“secondary diseases”), and cancers. The HIV virus can cause the disease AIDS (acquired immunodeficiency syndrome). It takes many years for an HIV infection to develop into AIDS. The presence of AIDS is confirmed if the T4 cell count is less than 200.

If a higher rating can be received by rating a secondary disease or infection than can be received by rating HIV or AIDS, then it can be rated under that secondary condition. A rating for both, however, is not allowed—only a rating for HIV or a rating for ONE of the secondary conditions, whichever can provide the higher rating. If it is rated on one of the secondary conditions, then the final code will look like this: 6351-4901. The first four-digit code defines the condition as HIV, and the second four-digit code tells how the condition is rated.

The ratings:

If there is an active AIDS disease with either regularly occurring infections/diseases or infections/diseases in numerous areas of the body, it is rated 100%. A 100% rating is also given for HIV if there is a secondary disease that is present the majority of the time and causes continual weight loss.

If there is a secondary disease, infection, or neoplasm as a result of AIDS, then the minimum rating is 60%. This rating is also given if there are significant symptoms throughout the body that cannot be controlled, diarrhea, and weight loss.

If the HIV is being treated by “approved” medication (medications that are prescribed for research by a qualified medical institution), but there are still regularly occurring symptoms throughout the body and intermittent diarrhea, then it is rated 30%. This rating is also the minimum rating given if the T4 cell count is less than 200, there is hairy cell leukoplakis, or oral candidiasis.

If the HIV is being treated by “approved” medication, there are at least definite symptoms present, and the T4 cell count is between 200 and 500, then it is rated 10%. If there are clear signs of depression or memory loss that interfere with the ability to work, a rating of 10% may also be given.

If there are no symptoms that affect the ability of the individual to function, then it is rated 0%, even if there is a decreased T4 cell count, disease in the lymph nodes, or diagnosed AIDS.

-Proposed- Code 6351: HIV (human immunodeficiency virus) is a virus mostly spread by sexual contact with an infected person, although it can also be spread from mother to child or by contact with infected blood. The virus attacks “T4” cells that support the immune system of the body, thus causing the body to be very vulnerable to infections, other diseases (“secondary diseases”), and cancers. 

The HIV virus can cause the disease AIDS (acquired immunodeficiency syndrome). It takes many years for an HIV infection to develop into AIDS. The diagnosis of AIDS is confirmed if the T4 cell count is less than 200 or if there is the presence of one of the following opportunistic infections in addition to HIV.

Opportunistic Infections
- Candidiasis of the bronchi, trachea, esophagus, or lungs
- Invasive cervical cancer
- Coccidioidomycosis
- Cryptococcosis
- Cryptosporidiosis
- Cytomegalovirus (including CMV retinitis)
- Encephalopathy
- Herpes simplex-chronic ulcers (must be present more than 1 month)
- Bronchitis
- Pneumonia
- Esophagitis
- Histoplasmosis
- Chronic intestinal isosporiasis
- Kaposi’s sarcoma
- Lymphoma
- Mycobacterium avium complex
- Tuberculosis
- Pneumocystis jirovecii pneumonia
- Recurrent pneumonia
- Progressive multifocal leukoencephalopathy
- Recurrent Salmonella septicemia
- Toxoplasmosis of the brain
- Wasting syndrome

Secondary diseases or infections, like diagnosed mental disorders, opportunistic infections, neoplasms, and central nervous system conditions, may be rated separately in addition to a rating under this code as long as symptoms do not overlap (Pyramiding Principle). For example, chronic bronchitis can be rated in addition to a rating under this code as the ratings cover different symptoms. However, a rating for Major Depressive Disorder cannot be given in addition for a 10% rating based on depression under this code as they both are rating the symptom of depression. In these cases, only one rating can be given. 

The ratings:

If there is AIDS and an opportunistic infection or a disease that affects numerous areas of the body, it is rated 100%. A 100% rating is also given for HIV if there is a secondary disease that is present the majority of the time and causes continual weight loss.

If there is an opportunistic infection or neoplasm, then the minimum rating is 60%. This rating is also given if there are diarrhea, weight loss, and other significant symptoms throughout the body that cannot be controlled.

If the HIV is being treated by “approved” medication (medications and treatment regimens that are prescribed for research by a qualified medical institution), but there are still regularly occurring symptoms throughout the body and intermittent diarrhea, then it is rated 30%. This rating is also the minimum rating given if the T4 cell count is less than 200.

If the HIV is being treated by “approved” medication, there are definite symptoms present, and the T4 cell count is between 200 and 500, then it is rated 10%. If there are clear signs of depression or memory loss that interfere with the ability to work, a rating of 10% is also given.

If there are no symptoms that affect the ability of the individual to function, then it is rated 0%, even if there is a decreased T4 cell count and lymph node disease.

The VA is proposing a number of changes to this code to better rate HIV based on current medical understandings and treatments. The VA proposes adding a list of opportunistic infections to help diagnose the presence of AIDS and allow for more clarity when rating secondary conditions. They are further clarifying that secondary conditions can be rated in addition to a rating under this code as long as there is no pyramiding. 
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-Current- Code 6354: Chronic fatigue syndrome is a condition where there is a long-term severe loss of energy. Many different conditions can produce significant fatigue, so a diagnosis of chronic fatigue syndrome can only be made after proper testing for all other possible conditions is done. The fatigue also has to be severe enough to limit the ability to perform daily activities by half for at least 6 months. Finally, there must be at least 6 or more of the following symptoms present: fever, tender lymph nodes, muscle aches or weakness, sore throat, debilitating fatigue lasting 24 hours or more after exercise, headaches unique to the fatigue (different than headaches before the fatigue began), joint aches, and cognitive problems (bad concentration, forgetfulness, confusion, etc.). 

Note: If the condition requires bed rest prescribed by the physician, then it is considered “incapacitating” during the period of bed rest.

If the symptoms are constant or so severe that it is impossible to perform daily activities, it is rated 100%.

If the symptoms do not completely limit activity, but your activity level is limited to at least half of what it was before the fatigue, or if the symptoms are not constant but there are periods of incapacitation that add up to at least 6 weeks within the past year, then it is rated 60%.

If the symptoms are fairly constant but you can still perform 50 to 75% of the normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 4 and 6 weeks within the past year, then it is rated 40%.

If the symptoms are fairly constant but you can perform 75% or more of your normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 2 and 4 weeks within the past year, then it is rated 20%.

If the symptoms are not constant but there are periods of incapacitation that add up to between 1 and 2 weeks within the past year, or if the symptoms are controlled by constant medication, then it is rated 10%.

-Proposed- Code 6354: Systemic exertion intolerance disease (“chronic fatigue syndrome (CFS)” or “myalgic encephalomyelitis (ME)”) is a condition where there is a long-term severe loss of energy. Many different conditions can produce significant fatigue, so a diagnosis of chronic fatigue syndrome must meet the following criteria:

1. Chronic fatigue severe enough to limit the ability to perform daily activities and work.
2. The presence of at least four of the following:
- debilitating fatigue lasting 24 hours or more after exercise
- unrefreshing sleep
- significant loss of concentration and short-term memory
- muscle pain
- joint pain (without swelling or redness)
- headaches different than headaches previously known
- tender lymph nodes
- frequent, recurring soar throat
3. These symptoms must have been present (or recurred regularly) for at least six months, are not caused by other conditions or by ongoing exertion, and did not first appear before the fatigue.

CFS cannot be diagnosed if:
- There is a current condition (or treatment) that is known to cause chronic fatigue, like sleep apnea, hyperthyroidism, narcolepsy, or numerous medications.
-Illnesses, like some cancers, hepatitis B or C, etc., that could cause chronic fatigue have been diagnosed but not fully resolved.
- Major depressive disorder with psychotic or melancholic features, bipolar affective disorders, anorexia nervosa, bulimia nervosa, schizophrenia, any delusional disorder, or dementia, have ever been diagnosed. 
- There is or has been alcohol or other substance abuse occurring within two years before or any time after the onset of fatigue.
- There is current severe obesity (BMI >45). 
- There is clinical testing or examination resulting in suspicion of one of the above conditions. In these cases, the condition must be diagnosed and treated before a diagnosis of CFS can be revisited.  

The Ratings:

Note: “Periods of incapacitation” only exist if a physician prescribes periods of bed rest and treatment. 

If the symptoms are constant or so severe that it is impossible to perform daily activities, it is rated 100%.

If the symptoms do not completely limit activity, but your activity level is limited to at least half of what it was before the fatigue, or if the symptoms are not constant but there are periods of incapacitation that add up to at least 6 weeks within the past year, then it is rated 60%.

If the symptoms are fairly constant but you can still perform 50 to 75% of the normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 4 and 6 weeks within the past year, then it is rated 40%.

If the symptoms are fairly constant but you can perform 75% or more of your normal daily activity, or if the symptoms are not constant but there are periods of incapacitation that add up to between 2 and 4 weeks within the past year, then it is rated 20%.

If the symptoms are not constant but there are periods of incapacitation that add up to between 1 and 2 weeks within the past year, or if the symptoms are controlled by constant medication, then it is rated 10%.

The VA proposes to change the name of this condition to ensure inclusion of any condition that causes severe fatigue with exertion. They also propose to update the diagnostic criteria to the current medical norms and to specify when a diagnosis cannot be made. The ratings themselves will not change.