Again, in only a matter of days, the VA
published a second section of proposed VASRD changes—after almost a year break—apparently
trying to make up for lost time. On August 1
st, the proposed changes
to the ratings of the Musculoskeletal System were made public.
The rewrite of the VASRD began in 2014 with
the goal to be finished by the end of 2016. With significant delays, and many
more sections left to go, there is no longer any clear timeframe as to when
veterans can expect these changes to be finalized, although if they continue
releasing changes at this rate, it won’t be much longer.
So far, only the ratings for Mental Disorders have officially been updated, although the VA just published the
final ruling for the changes to Dental and Oral Conditions a few days ago.
We’ll have info regarding those coming up soon. Those changes will go into
effect in September.
With each set of proposed changes, the VA
allows a period in which comments can be submitted. The VA then takes each
comment into consideration and makes any additional changes that are warranted
before publishing the final ruling.
We encourage you to submit any comments you
might have on these proposed changes to us either by commenting on this post or
by contacting us through our website. All comments must be received by
September 20th, 2017. We will then compile all of your comments into a single
report and submit it on your behalf to the VA, just as we did for the other
sections (see the Female Reproductive System Comments). This is a great
opportunity to really make a difference, so please let us know your thoughts.
The following are the VA’s proposed changes
to the ratings for the Musculoskeletal System. The Musculoskeletal System is so
vast, that we’ve broken it down into multiple pages on our site. Use the links
below to find our discussions of the current ratings for these conditions.
The changes are fairly extensive, so I’ll
walk through each, one at a time. If you don’t want to have to plod through
them all, it might be most effective to just search for keywords (command-F
works great!).
For each condition, the small, indented
parts are the codes as they are right now. Click on the links to be taken to
the discussion of that code on our site. After the current code, I’ll discuss
the proposed changes and the VA’s justification.
___________________________________________________________________________
Code 5000 for osteomyelitis
remains exactly the same.
___________________________________________________________________________
Code 5001 for tuberculosis of the musculoskeletal system remains exactly the
same.
___________________________________________________________________________
-Current- Code 5002: Rheumatoid
arthritis is the destruction of the soft tissues in a joint
because of swelling.
Regardless of how many
joints are affected, if the arthritis is severe enough that you cannot
function, but are completely incapacitated and bedridden, then it is rated
100%.
If there is significant
weight loss, anemia, and overall severe decrease in health but not complete
incapacitation, or if severe incapacitating episodes happen 4
or more times a year, then it is rated 60%.
If there is a definite
decline in overall health, or if incapacitating episodes
happen 3 or more times a year, then it is rated 40%.
One or two episodes a year
rates 20%.
These ratings cannot be used in addition to ratings
for limited motion. One or the other. Any rheumatoid arthritis less severe than
noted above is just rated upon its symptoms, such as
limited motion. In these cases individual joints can be rated. So, if three
joints are involved, but there are no incapacitating episodes, all three can be
rated separately on limited motion. A minimum of 10% is given for every joint
that at least has pain with motion.
-Proposed- Code 5002: Multi-joint systemic arthritis includes
any arthritis diseases (including rheumatoid
arthritis, psoriatic arthritis,
etc.) that affect multiple joints in the body and could affect other body
systems as well. To be rated under this code, there must be a definite
diagnosis, the arthritis must be active, and at least 2 joints must be affected.
This code does not cover post-traumatic arthritis or gout.
If the arthritis is severe enough that you
cannot function, but are completely incapacitated and bedridden, then it is
rated 100%.
If there is significant weight loss, anemia,
and overall severe decrease in health but not complete incapacitation, or if
severe incapacitating episodes happen 4 or more times a year, then it is rated
60%.
If there is a definite decline in overall
health, or if incapacitating episodes happen 3 or more times a
year, then it is rated 40%.
One or two episodes a year rates 20%.
Any arthritis no longer active or less severe than noted above is rated
under code 5003 as degenerative arthritis. Multiple ratings, however, cannot be
given. Any rating under this code cannot be combined with ratings for
degenerative arthritis or limited motion in the same joints. Instead, the code
that can offer the higher rating is used.
Although the ratings
themselves did not change, the VA wanted to expand this code to cover all
systemic arthritis, not just rheumatoid arthritis. The only other significant
change was to rate lesser conditions as degenerative arthritis instead of just
on limited motion.
_________________________________________________________________________
The only change for Code 5003 for degenerative arthritis is to adjust the
name of the code to specify that this is for all degenerative arthritis except
post-traumatic degenerative arthritis. The ratings remain exactly the same.
_________________________________________________________________________
Codes 5004-5008 for gonorrheal arthritis, pneumococcic arthritis, typhoid arthritis,
syphilitic arthritis, and streptococcic
arthritis, continue to be rated under code 5002 for any active disease and
code 5003 for anything that doesn’t qualify for those ratings.
_____________________________________________________________________
-Current- Code 5009: All other arthritis is
rated under this code.
-Proposed- Code 5009: All other diseases of the joints (except gout) are rated under
this code. All active diseases are rated under code 5002, systemic arthritis.
Anything that doesn’t qualify for a rating under that code is rated under code
5003, for degenerative arthritis.
The VA adjusted this code to include any
other disease that would affect the joints, not just arthritis.
______________________________________________________________________
-Current- Code 5010: Post-traumatic
arthritis is arthritis that is due to an accident or injury. This code
doesn’t have its own ratings, but is rated as degenerative
arthritis. The final code for this condition will look like this: 5010-5003. The first four-digit code defines the condition as traumatic
arthritis, and the second four-digit code tells how it is rated.
-Proposed- Code 5010: Post-traumatic arthritis is
arthritis caused by an accident or injury. This condition is rated as limited
motion, dislocation, or instability of the joint affected, whichever one
is ratable for that joint and gives the higher rating. Multiple ratings for a
single joint cannot be combined unless the codes specifically state that they
can (as is the case for instability of the knee). Each joint receives its own
rating.
Degenerative arthritis is just rated on
limited motion of the joint, so the changes to this code allow instability and
dislocation to be considered as a legitimate rating option instead of just
limited motion.
_____________________________________________________________________
-Current- Code 5011: Caisson disease is
the premature death of bone and marrow cells, often caused by compressed air
most often seen in divers. It is rated based on its most prevalent symptom. For
example, if it affects the spinal cord and causes limited motion in the hip, it
would be rated under that symptom. Common symptoms include deafness, arthritis
in the joints, loss of motion, etc. Only the symptom that can give the highest rating can be rated for this condition. The
final code for this condition would look like this: 5011-5261. The first
four-digit code identifies the condition as caisson disease, and the second
four-digit code tells what symptom the condition is rated under.
-Proposed- Code 5011:
Decompression sickness (a.k.a. caisson disease, divers’
disease, or the bends) occurs when gas bubbles form in the
body because of decompression. The most common symptom is joint pain, however,
since the bubbles can form in any part of the body, a variety of symptoms can
occur, including arthritis,
nerve and/or brain damage,
hearing loss,
skin damage,
lung damage, and more. This condition is rated on its symptoms. So if
it causes a rash on the skin and joint pain, it would be rated under
arthritis
and
dermatitis. Each symptom receives its own rating as long as a single
symptom is not rated twice (see the
Pyramiding Principle).
The VA intends to
expand this code to include any symptom caused by decompression sickness, not
just ones related to the musculoskeletal system.
__________________________________________________________________
Code 5012 for malignant bone cancer essentially remains the same. They updated
some wording to modern medical jargon, but it has no effect on interpretation
or rating.
___________________________________________________________________
Both code 5013, for osteoporosis, and code 5014, for osteomalacia, are basically remaining the same. The VA simply added
“residuals of” to the requirements to show that the conditions themselves
aren’t ratable—it’s the symptoms that they cause in the joints that are
ratable. Ultimately, nothing really changes. This principle was already
basically accepted and applied in ratings, they just wanted to make it super
clear.
___________________________________________________________________
Code 5015 for non-cancerous bone growth (“neoplasms”) remains the same.
____________________________________________________________________
____________________________________________________________________
Code 5017 for gout is currently rated under code 5002, rheumatoid arthritis.
Under the proposed changes, it says that it should be rated under code 5003,
which is the code for degenerative arthritis. We believe that this is a typo on
the VA’s part, as they do not comment on such a large change, and in fact,
state that no real change occurred to this code. We believe that it will
continue to be rated under code 5002.
____________________________________________________________________
The VA proposes to remove the following codes:
-Current- Code 5018: Intermittent
hydrarthrosis is the periodic swelling most commonly of major joints,
although other joints could also be affected, on a regular and predictable
schedule.
-Current- Code 5020: Synovitis is the
swelling of a membrane that lines synovial joints.
-Current- Code 5022: Periostitis is
the swelling of the tissue that surrounds the bones.
Based on modern
medical practices, these conditions are actually symptoms of larger conditions,
like rheumatoid arthritis, and so should not be treated as stand-alone
conditions. Instead, any disability they cause is already covered by the rating
of the main condition.
___________________________________________________________________
Codes 5023 for myositis ossificans remains the same, but the name is changed to heterotopic ossification. This is the
term for this condition that is currently the accepted norm.
___________________________________________________________________
The name for code 5024 is changed to
include not only tenosynovitis, but
also tendinitis, tendinosis, and tendinopathy. All of these conditions should
already be rated under this code, but this makes it more clear exactly where
these conditions are intended to be rated.
___________________________________________________________________
___________________________________________________________________
Prosthetic
Implants and Resurfacing
For all codes 5051-5056 for the prosthetic
replacement of joints and resurfacing, a note is added that specifies that no
other musculoskeletal rating can be given in addition to this code. Separate
ratings can be given for nerve conditions or scars caused by these procedures,
but not for arthritis, limited motion, etc. Only one musculoskeletal rating per
condition.
Besides the above note, codes 5051-5053 and
5056 for shoulder, elbow, wrist, and ankle replacements remain the same.
-Current- Code 5054: If either the entire
head of the femur or entire head of the acetabulum has been
replaced by a false joint prosthesis, then the condition is rated 100%
for the first year after the surgery. (This period is mainly for the VA, but
the DoD will also use it if the veteran is placed on TDRL before being permanently
separated). After the 1-year period, the condition is given a permanent rating.
If there is weakness and severe pain with motion that requires the use of
crutches, then it is rated 90%. If there is weakness and severe pain, but it
does not require crutches, then it is rated 70%. If the pain is not severe, but
does limit the range of motion, then it is rated 50%. The minimum rating for a
hip replacement is 30%.
If your condition rates 90% under this code, you may
also qualify for additional compensation by the VA. Please
see the Special Monthly
Compensation page for more information.
-Proposed- Code 5054: If the hip
has been resurfaced or if either the entire head of the
femur or entire head of the acetabulum has been replaced by
a false joint prosthesis, then the condition is rated 100% for the first 4
months after the surgery. (This period is mainly for the VA, but the DoD will
also use it if the veteran is placed on TDRL before being permanently separated). After the 4-month period, the
condition is given a permanent rating.
For joint replacements:
If there is weakness and severe pain with motion that requires the use of
crutches, then it is rated 90%. If there is weakness and severe pain, but it
does not require crutches, then it is rated 70%. If the pain is not severe, but
does limit the range of motion, then it is rated 50%. The minimum rating for a
hip replacement is 30%.
If your condition rates 90% under this code, you may also
qualify for additional compensation by the VA. Please see the Special Monthly Compensation page for more information.
-Current- Code 5055: If the entire knee joint
has been replaced by a prosthesis, then the condition is rated 100% for the
first year after the surgery. (This period is mainly for the VA, but the DoD
will also use it if the veteran is placed on TDRL before being permanently
separated). After the 1-year period, the condition is given a permanent rating.
If there is weakness and severe pain with motion, then it is rated 60%. If the
pain is not severe, but does limit the range of motion, then it is rated under
code 5256 if it is frozen, or under codes 5261 or 5262, discussed below, if it
is not frozen. The minimum rating for a total knee replacement, however, is 30%
regardless of how much motion it has.
Note: This code is only for total knee replacements.
Partial replacements are rated on any symptoms that they cause, like limited
motion.
-Proposed- Code 5055: If the knee
has been resurfaced or If
the entire knee joint has been replaced by a prosthesis, then the
condition is rated 100% for the first 4 months after the surgery. (This period
is mainly for the VA, but the DoD will also use it if the veteran is placed on TDRL before being permanently
separated). After the 4-month period, the condition is given a permanent
rating.
For replacements: If there is
weakness and severe pain with motion, then it is rated 60%. If the pain is not
severe, but does limit the range of motion, then it is rated under code 5256 if
it is frozen, or under codes 5261 or 5262, discussed below, if it is not
frozen. The minimum rating for a total knee replacement, however, is 30%
regardless of how much motion it has.
Note: This code is only for total knee replacements. Partial
replacements are rated on any symptoms that they cause, like limited motion.
Joint resurfacing is now a common
alternative for joint replacements for the hip and the knee. While they provide similar disability as a
joint replacement, they do not qualify under the current rating requirements.
Thus the VA proposes to adjust code 5054 and 5055 to include resurfacing. Resurfacing,
however, creates a shorter convalescent period and fewer long-term
disabilities. Thus, they propose only a 4 month 100% rating period and then
alternative rating options for remaining symptoms after the resurfacing.
____________________________________________________________________
____________________________________________________________________
Code 5106 for both hand amputation remains the same.
____________________________________________________________________
Code 5107 for both foot amputation remains the same.
____________________________________________________________________
Code 5109 for loss of use of both hands remains the same.
____________________________________________________________________
Code 5110 for loss of use of both feet remains the same.
____________________________________________________________________
Code 5111 for loss of use of one hand and one foot remains the same.
_____________________________________________________________________
-Current- Code 5120: If the entire arm is
amputated from the shoulder joint down, it is rated 90% for
either arm.
-Proposed- Code 5120: If the entire arm is
amputated from the top of the humerus down, it is rated 90% for either arm. If
the amputation includes the shoulder, including the scapula, clavicle, and/or
ribs, it is rated 100% for either arm.
The VA proposes adding
a 100% rating option for amputees with more than just the shoulder joint and
arm removed. The further removal of ribs and the shoulder results in a higher
level of disability as prosthetics are much more difficult, if not impossible,
to use.
______________________________________________________________________
Codes 5121-5156 for various amputations of the arms, hands, and fingers
remain the same.
______________________________________________________________________
-Current- Code 5160: If
the entire leg is amputated at the hip joint, it is rated 90%.
-Proposed- Code 5160: If the entire hip is amputated from the top of the femur down,
it is rated 90%. If the amputation includes any part of the pelvic bones as
well, it is rated 100%.
If the amputation causes any bladder or bowel
problems, they can be rated separately.
The VA proposes adding
a 100% rating option for amputees with more than just the hip joint and leg
removed. The further removal of the pelvis results in a higher level of
disability as prosthetics are much more difficult, if not impossible, to use.
_____________________________________________________________________
Codes 5161-5167 and 5171-5173 for various amputations of the legs, feet, and toes remain
the same.
______________________________________________________________________
-Current- Code 5170: If all of the toes are
amputated, not including the ball of the foot, it is rated 30%.
-Proposed- Code 5170: If all of the toes are
amputated, not including the ball of the foot, it is rated 30%. This can
include up to half of the metatarsals, but less than the entire ball of the
foot.
The VA wants to clarify that anything more
than all of the toes but less than the ball of the foot should be rated under
this code.
_______________________________________________________________________
Code 5200 for a frozen shoulder joint remains the same.
_______________________________________________________________________
The VA changed some of the phrasing in code 5201 for limitation of motion of the
shoulder, but it effectively remains exactly the same.
_______________________________________________________________________
_______________________________________________________________________
Codes 5203-5213 for all other conditions of the shoulder and arm remain the same.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Code 5242 for degenerative arthritis of the spine is further expanded to include
degenerative disc disease and all other disc conditions (except intervertebral
disc syndrome). The ratings remain the same.
_______________________________________________________________________
Code 5243 for intervertebral disc syndrome remains the same.
_______________________________________________________________________
-NEW
Proposed- Code
5244: Both paraplegia and quadriplegia are rated under this code.
Paraplegia is the complete paralysis of the legs and lower body. It is rated
100% under code 5110, complete loss of use of the feet. This condition is also
entitled to Special Monthly Compensation.
Quadriplegia is the complete paralysis of
both the arms and the legs. It is given two ratings: 100% under code 5110 for
complete loss of use of the feet, and 100% under code 5109 for complete loss of
use of the hands. Having two 100% ratings qualifies the veteran for a higher
level of Special Monthly Compensation.
_______________________________________________________________________
_______________________________________________________________________
-Current- Code 5255: Any problems with the femur
or femoral neck bones are rated under this code. If either is
completely broken through and it causes loose or erratic leg motion, then it is
rated 80%. If it is broken through but the leg motion is not loose and the leg
can support weight with the help of a brace, then it is rated 60%. If it is
fractured and has a false joint, it is rated 60%.
All other femur bone conditions are rated by how they
affect the hip or knee joint. If they cause serious problems (can barely use
the joint at all), then it is a 30% rating. If the joints can be used, but the
condition significantly limits the amount of activity,
then it is rated 20%. If the hip or knee joint is affected only slightly, then
it is rated 10%.
-Proposed- Code 5255: Any problems with the femur or
femoral neck bones are rated under this code. If either is completely
broken through and it causes loose or erratic leg motion, then it is rated 80%.
If it is broken through but the leg motion is not loose and the leg can support
weight with the help of a brace, then it is rated 60%. If it is fractured and
has a false joint, it is rated 60%.
All other femur bone conditions are rated by how they affect the hip or
knee joint, whichever results in a higher rating. Rating options for the knee
include code 5256, code 5257, code 5260, or code 5261. Rating options for the
hip include, codes 5250-5254. Only one code can be assigned for this condition.
The VA recognizes that the current language
for these ratings is rather vague. It’s hard for “marked” to be regularly
defined by every rating authority, etc. Because of this, ratings for femur bone
conditions aren’t standard across the board. To fix this, the VA suggests
rating it instead on exactly how the knee or hip are affected, thus eliminating
guesswork.
____________________________________________________________________
Code 5256 for no motion of the knee
remains the same.
____________________________________________________________________
-Current- Code 5257: The knee can have too
much motion (instability) from side to side or dislocate
regularly. This can happen when the tendons and cartilage are damaged and can
no longer support the knee joint properly. If there is only slight instability,
then it is rated 10%. If there is more instability that might cause the knee to
buckle or dislocate every now and then, then it is rated 20%. If, however, it
is so unstable that it gives out or dislocates regularly, it is rated 30%.
Code 5257: The knee can also have too much
motion (instability) from side to side or dislocate (subluxation) regularly. This can happen
when the tendons and cartilage are damaged and can no longer support the knee
joint properly. Similarly injuries can cause the kneecap instability, causing it to shift out of position.
For general instability and subluxation:
If surgery was performed, there is still 11mm or more of abnormal joint
motion, and a physician prescribed both a brace and a device to
help with walking (crutch, walker, cane, etc.), it is rated 30%.
If surgery wasn’t performed, there is 11mm or more of abnormal joint
motion, and a physician prescribed both a brace and a device to help
with walking (crutch, walker, cane, etc.), it is rated 20%.
With any amount of abnormal motion, if a physician prescribes either a
brace or a device to help with walking, it is rated 10%.
For kneecap instability:
If the kneecap continues to be unstable after surgery is performed, it
is rated 30%. The surgery must have been done specifically to fix the
instability. Surgery to remove bone fragments or other knee surgeries that do
not address the instability do not qualify.
If surgery was not performed, but there is regular kneecap instability and
there are one or more abnormalities in the knee (damage to the ligaments,
bone flakes in the knee, breaks or other issues with the kneecap itself, damage
to the femoral trochlea, etc.), it is rated 20%.
If surgery was not performed, there is regular kneecap instability, but
there are no other abnormalities, it is rated 10%.
The VA proposes more
measureable rating requirements for instability of the knee. Since “mild,”
“moderate,” and “severe” are difficult to uniformly define, more specific
criteria is needed to eliminate inconsistent ratings. They also propose adding
ratings specific to kneecap instability. The kneecap is not sufficiently
addressed at all under the current ratings.
______________________________________________________________________
______________________________________________________________________
-Current- Code 5262: Any problems with the tibia
or fibula bones in the lower leg are rated under this code. If there
is a complete break in either bone that cannot heal and requires a brace, then
it is rated 40%. All other conditions are rated by how
they affect the knee or ankle joint. If they cause serious problems (can barely
use the joint at all), then it is a 30% rating. If the joints can be used, but
the condition significantly limits the amount of activity, then it is rated
20%. If the knee or ankle joint is affected only slightly, then it is rated
10%.
-Proposed- Code 5262: Any problems with the tibia or fibula
bones in the lower leg are rated under this code.
If there is a complete break
in either bone that cannot heal and requires a brace to stabilize, then it is
rated 40%.
Medial tibial stress syndrome (a.k.a. “MTSS”
or “shin splints”) must be
officially diagnosed by x-ray, bone scan, or MRI in order to qualify for a
compensable rating.
If both legs are affected, it has been treated consistently for 12
months or more, and it is not responsive to any form of treatment, it is
rated 30%.
If only one leg is affected, it has been treated consistently for 12
months or more, and it is not responsive to any form of treatment, it is
rated 20%.
If one or both legs are affected, it has been treated consistently for
12 months or more, and it is only unresponsive to conservative treatments (like
orthotics), it is rated 10%.
If the condition has been treated for less than 12 months, it is rated
0%.
All other conditions (including malunion) are rated by how they affect
the knee or ankle joint, whichever results in a higher rating. Rating options
for the knee include code 5256, code 5257, code 5260, or code 5261. Rating
options for the ankle include, codes 5270-5271. Only one code can be assigned
for this condition.
Again, the VA is trying to get rid of vague
language that leaves too much up to interpretation. Thus instead of rating
other conditions on “moderate,” etc., they suggest rating them on the actual
impairment of the joints affected. The proposed ratings also add separate
rating criteria for shin splints, a condition previously ignored in the
ratings.
______________________________________________________________________
Code 5263 for genu recurvatum remains the same.
______________________________________________________________________
______________________________________________________________________
-Current- Code 5271: If the ankle is
not frozen, but limited in motion, then it is rated under this
code. Normal range of motion for the ankle is 0° to 20° dorsiflexion and 0° to
45° plantar flexion. A 20% rating is given for a markedly limited range of
motion and a 10% is given for a moderately limited range of motion.
-Proposed- Code 5271: If the ankle is not frozen,
but limited in motion, then it is rated under this code. Normal
range of motion for the ankle is 0° to 20° dorsiflexion and 0° to 45° plantar
flexion.
If dorsiflexion is less than 5° or plantar flexion is less than
10°, it is rated 20%. If dorsiflexion is between 5° and 14° or plantar
flexion is between 10° and 29°, it is rated 10%.
The VA proposes to get rid of the vague
“marked” and “moderate” requirements and instead define the exact range of
motions necessary for the ratings.
_______________________________________________________________________
Code 5275 for shortening of the bones
remains the same.
_______________________________________________________________________
_______________________________________________________________________
-NEW Proposed- Code 5285: Plantar
fasciitis is a condition
where the skin and tissues on the bottom of the foot swell and cause pain. If
both feet are affected, and the symptoms are not responsive to any kind of
treatment, including surgery, it is rated 30%. If only one foot is affected,
and the symptoms are not responsive to any kind of treatment, including
surgery, it is rated 20%. If the symptoms are treatable, it is rated 10%.
If the condition is not responsive to treatment and is so severe that
the foot cannot be used at all, it is rated 40% under code 5167 for loss of use
of the foot.
The VA proposes to add this code because
plantar fasciitis is a common enough condition that it should be given its own
rating system.
_____________________________________________________________________
______________________________________________________________________
All codes for Muscle Ratings remain the
same except for the addition of the following two new codes:
-NEW Proposed- Code 5330: Rhabdomyolysis is a condition where the
muscles break down rapidly, usually due to trauma or overuse. Each muscle group
affected is rated separately. So if a crush injury causes rhabdomyolysis in the
forearm and hand, affecting all three of the muscle groups in that area, it
will be given three separate ratings.
Additionally, as
the muscles break down and are absorbed into the blood, the kidneys can be
damaged. Because of this, any kidney damage caused by rhabdomyolysis can be
rated separately.
-NEW Proposed- Code 5331: Compartment
Syndrome is a condition where pressure builds up rapidly in the tissues,
usually due to a trauma or overuse, and cuts off the blood supply to an area of
muscle. Each muscle group affected is rated separately. So if a crush injury
causes compartment syndrome in the forearm and hand, affecting all three of the
muscle groups in that area, it will be given three separate ratings.
The VA proposes to add these two new codes
to help the rating authorities know how best to rate these conditions. Currently
they are rated analogously on any muscle groups that are damaged, but these
codes make the requirements more clear. Hopefully it will avoid improper
ratings.
____________________________________________________________________