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Tuesday, October 15, 2019

-NEW- Proposed Changes to the Ratings of the Genitourinary System

On July 28th, 2017, the VA published proposed changes to the ratings of the Genitourinary System, but they withdrew those proposed changes in March of this year because there were errors in the rating criteria.

Today, October 15th, 2019, the VA published their revised proposal for changes to the ratings of the Genitourinary System. Since it will be too confusing to discuss the differences between the original proposal as well as the differences between the current system, I am only going to focus on the changes that will occur if these new proposed changes go into effect. If curious, you can find the original proposal here

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 December 1st, 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 new proposed changes to the ratings for the Genitourinary System. The changes to the current system are fairly extensive, so I’ll walk through them, one at a time.

For each condition, the small, indented parts are the codes as they are right now. Click on the links to be taken to the discussion of that code on our site. After the current code, I’ll discuss the proposed changes and the VA’s justification. 
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The Urinary Rating Systems remain exactly the same. No changes proposed. 
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All Urinary Conditions (codes 7512, 7515, 7516, 7517, 7518, and 7519) are staying the same, except: 

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

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

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

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

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

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

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

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

-Proposed- The ratings: 

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

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

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

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

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

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

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

Code 7501 for abscess of the kidney remains the same. 

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

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

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

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

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

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

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

-Proposed- In order to qualify for ratings 30%-100%, a chronic kidney disease must be diagnosed. 
 A 100% rating is given if at least one of the following is present:
– A GFR (glomerular filtration rate) less than 15mL/min/1.73 mfor a minimum of 3 consecutive months
– The condition requires regular dialysis.
– A kidney transplant has been performed
An 80% rating is given if the GFR is between 15 and 29 mL/min/1.73 mfor a minimum of 3 consecutive months
A 60% rating is given if the GFR is between 30 and 44 mL/min/1.73 mfor a minimum of 3 consecutive months.
A 30% rating is given if the GFR is between 45 and 59 mL/min/1.73 mfor a minimum of 3 consecutive months
A 0% rating is given in the following symptoms are present for at least 3 consecutive months, even if a chronic kidney disease has not yet been diagnosed:
– The GFR is between 60 and 89 mL/min/1.73 m2 and there are recurrent red blood cell casts, white blood cell casts, or granular casts
– The GFR is between 60 and 89 mL/min/1.73 m2 and there are abnormalities in the kidneys structure (cysts, obstruction, etc.)
– The GFR is between 60 and 89 mL/min/1.73 m2 and the albumin/creatinine ratio (ACR) is 30 mg/g or more 
Note: Both estimated GFR (eGFR) and creatinine based approximations of GFR will be accepted for GFR ratings as long as they are calculated by a qualified physician. 

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

The VA recognizes that the additional rating criteria is necessary to ensure that the full picture of the disease is taken into account for rating purposes. This is especially important for the 0% ratings, as a high GFR may not mean that the kidney isn’t impaired and causing symptoms. Thus additional symptoms are taken into account to reflect the increased risk for the development of chronic kidney disease. 

The 100% rating for individuals post-kidney transplant is another important addition. 
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Renal (Kidney) Conditions

The following conditions will still be rated on the renal rating system, but the new one proposed above. 

Code 7500 for nephrectomy remains the same.

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

NEW NOTE FOR ALL RENAL CONDITIONS:

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

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

Code 7504 for pyelonephritis remains the same. 

Code 7507 for nephrosclerosis remains the same. 

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

Code 7531 for a kidney transplant remains the same. 

Code 7532 for renal tubular conditions remains the same. 

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


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

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

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

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

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

Code 7535 for toxic nephropathy remains the same. 

Code 7536 for glomerulonephritis remains the same. 

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

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

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

Code 7538 for papillary necrosis remains the same. 

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Code 7528 for malignant cancer remains exactly the same.

Code 7529 for benign tumors remains exactly the same.

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

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

  1. Question: I'm have 30% rating under Code 7508 Nephrolithiasis, have had kidney stones in past but no longer have. But have the rating approved under diet therapy. If the approved changes go into effect, removing the diet therapy, will I loose this rating?

    ReplyDelete
    Replies
    1. Until the final changes are published, it's impossible to predict how these rules will affect current ratings. In most cases, the changes are applied to new claims and do not change current ratings unless those conditions are submitted to for an increased evaluation or review in the future. It is possible that once these final changes are published, it includes a regulation to apply to all cases, not just new ones. But we won't know until they are published.

      If they do do that, then since diet therapy is not longer included, your condition would then be rated under code 7509 for hydronephrosis.

      Delete
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      Delete
  2. I posted here in the past about varicoceles and hydroceles GU has found since leaving service in 2000.
    The issue of not causing pain is untrue.
    When they fill and swell the pain is acute and walking is a burden. Now granted the infertility has already occured from this, but it does impede working after (for me anyway) 4 hours and takes resting/laying 4 or so to go away to a somewhat normal feel.
    Driving is impeded too dependent on the distance/bumps aggravate the time in car with force on the right side.

    Just saying.
    I am rated for ED 00%
    SMC-K1 for Infertility
    But for the continuous PAIN and UNCOMFORT nothing!
    But we know that because it was not an option for a claim!

    ReplyDelete
    Replies
    1. But I do agree with the Proposed Code for ED 7522.
      Unless you are in the other entertainment business and can prove it. With video. :) :)

      Delete
    2. As stated initially the MAX proposed rating for Code 7543 should be 10% with the frequency and pain and size references as objective evidence for such since (as in my case) it gets really bad and does interfere with working.

      But 10% MAX is what I do believe would suffice, as its primarily recorded at the VA anyway during the physical exams. And you can tell if some one is faking.

      Delete
    3. Great feedback on the ratings for code 7543. It definitely does not take into account the affect of pain on the ability to function in daily life. We'll make sure to submit your feedback to them, and hopefully get a positive response.

      Delete
  3. Dear Sir,
    I'm currently service connected for hearing loss with a 0% rating.C&P exam revealed the following:LEFT EAR, decimal loss of 33 with speech discrimination of 86%. RIGHT EAR, decimal loss of 38 with speech discrimination of 82%. I requested a hearing test from my primary physician and was referred to a ENT practice.The resulting audiogram showed: LEFT EAR, decimal loss of 33 with a speech discrimination of 72%. RIGHT EAR, decimal loss 35 with speech discrimination of 80%. Is a rate increased warranted? How should I proceed?...date of rating decision is approaching one year deadline in January. Called VA, was told to make "an intent to file, which I did, then submit 21-526EZ form, have not done this. Would it be better to make an appointment with area VA clinic audiologist and talk with them (ENT audiologist recommended doing this). Really confused... any suggestions/advice would be appreciated. Thank you.

    ReplyDelete
    Replies
    1. Yes, the more recent results qualify for a 10% rating. Check out the Hearing Loss Rating System for details:

      http://www.militarydisabilitymadeeasy.com/theears.html#system

      You can submit for an increased evaluation on a new Claim. The VA made the correct decision based on the information they had at the time, so you cannot appeal their decision. Instead, you can submit a new claim for an increased evaluation based on the more recent evidence. They may want to reexamine you themselves as well.

      http://www.militarydisabilitymadeeasy.com/vadisabilityclaim.html

      Delete
  4. I have been rated for service connected Type 2 Diabetes . I now have COPD and Sleep Apnea which I use a CPAP machine every night. Can I claim both of these conditions as secondary to my diabetes, or would it be best for me to claim them as stand alone issues.

    ReplyDelete
    Replies
    1. There is research that shows a relationship between diabetes and COPD, but none definitively prove that diabetes is the direct cause of COPD, although it can worsen it or increase the likelihood of it. If you can provide sufficient evidence in your case that your COPD (and sleep apnea) are a direct result of your diabetes, then your claim can be successful. You would need solid medical research as well as strong NEXUS letters from your physicians.

      If you are unable to provide enough evidence that the COPD is secondary to your Diabetes, then you can only apply for COPD and Sleep Apnea independently if you can prove their service-connection in another way.

      http://www.militarydisabilitymadeeasy.com/service-connected.html
      http://www.militarydisabilitymadeeasy.com/vapresumptivelist.html

      Delete
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