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Saturday, August 3, 2019

Proposed Changes to the Ratings of the Cardiovascular System


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

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

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

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

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

We encourage you to submit any comments you might have on these proposed changes to us either by commenting on this post or by contacting us through our website. All comments must be received by September 30th, 2019. We will then compile all of your comments into a single report and submit it on your behalf to the VA, just as we did for the other sections (see the Female Reproductive System Comments). This is a great opportunity to really make a difference, so please let us know your thoughts. 

The following are the VA’s proposed changes to the ratings for the Cardiovascular System. The changes are fairly extensive, so I’ll walk through each, one at a time.

For each condition, the small, indented parts are the codes as they are right now. Click on the links to be taken to the discussion of that code on our site. After the current code, I’ll discuss the proposed changes and the VA’s justification. 
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The majority of heart conditions are rated based on a set rating system.

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

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

The basic rating system:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  1. Is there any idea when this will take effect?

    ReplyDelete
  2. Unfortunately, no. The VA has taken from 3 months to a few years to publish the final changes to past sections. There is simply no way to know until they publish the final changes. They will then give an effective date for the changes that is typically 2 months or so after.

    ReplyDelete





  3. Will the changes effect existing disability claims?

    ReplyDelete
    Replies
    1. It will depend on the wording of the final ruling, which we can't predict. Most changes are applied to claims received on or after the effective date, but some include instructions to update current ratings to reflect the new system. It is most likely not going to affect current ratings, but again, until the final rule is published, there is no way to really know.

      Delete
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