Schedule for Rating Disabilities; Musculoskeletal System and Muscle Injuries, 35719-35733 [2017-15766]

Download as PDF Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules outcome of this rulemaking. If you submit a comment, please include the docket number for this rulemaking, indicate the specific section of this document to which each comment applies, and provide a reason for each suggestion or recommendation. We encourage you to submit comments through the Federal eRulemaking Portal at https:// www.regulations.gov. If your material cannot be submitted using https:// www.regulations.gov, contact the person in the FOR FURTHER INFORMATION CONTACT section of this document for alternate instructions. We accept anonymous comments. All comments received will be posted without change to https:// www.regulations.gov and will include any personal information you have provided. For more about privacy and the docket, visit https:// www.regulations.gov/privacyNotice. Documents mentioned in this NPRM as being available in the docket, and all public comments, will be in our online docket at https://www.regulations.gov and can be viewed by following that Web site’s instructions. Additionally, if you go to the online docket and sign up for email alerts, you will be notified when comments are posted or a final rule is published. List of Subjects in 33 CFR Part 165 Harbors, Marine safety, Navigation (water), Reporting and recordkeeping requirements, Security measures, Waterways. For the reasons discussed in the preamble, the Coast Guard proposes to amend 33 CFR part 165 as follows: PART 165—REGULATED NAVIGATION AREAS AND LIMITED ACCESS AREAS 1. The authority citation for part 165 continues to read as follows: ■ Authority: 33 U.S.C. 1231; 50 U.S.C. 191; 33 CFR 1.05–1, 6.04–1, 6.04–6 and 160.5; Department of Homeland Security Delegation No. 0170.1. 2. Add § 165. T07–0577 to read as follows: ■ mstockstill on DSK30JT082PROD with PROPOSALS § 165.T07–0577 Safety Zone, Blue Angels Air Show; St. Johns River, Jacksonville, FL (a) Regulated Area. The following area is a safety zone located on the St. Johns River in Jacksonville, FL. All waters of the St. Johns River encompassed within an imaginary line connecting the following points: Starting at Point 1 in position 30°13′41″ N.; 081°39′45″ W., thence due east to Point 2 in position 30°13″41″ N.; 081°38′35″ W., thence south to Point 3 in position 30°14′27″ N.; 081°38″35″ W., thence west to Point VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 4 in position 30°14′27″ N., 081°39′45″ W., thence following the shoreline north back to the point of origin. These coordinates are based on North American Datum 1983. (b) Definition. The term ‘‘designated representative’’ means Coast Guard Patrol Commanders, including Coast Guard coxswains, petty officers, and other officers operating Coast Guard vessels, and Federal, state, and local officers designated by or assisting the Captain of the Port Jacksonville in the enforcement of the regulated area. (c) Regulations. (1) All persons and vessels are prohibited from entering, transiting through, anchoring in, or remaining within the regulated area unless authorized by the Captain of the Port Jacksonville or a designated representative. (2) Persons and vessels desiring to enter, transit through, anchor in, or remain within the regulated area may contact the Captain of the Port Jacksonville by telephone at (904) 714– 7557, or a designated representative via VHF–FM radio on channel 16, to request authorization. If authorization is granted, all persons and vessels receiving such authorization must comply with the instructions of the COTP Jacksonville or a designated representative. (3) The Coast Guard will provide notice of the regulated area through Broadcast Notice to Mariners via VHF– FM channel 16 or by on-scene designated representatives. (d) Enforcement Period. This rule will be enforced daily from 8 a.m. until 5 p.m. from November 3, 2017 through November 5, 2017. Dated: July 27, 2017. T.C. Wiemers, Captain, U.S. Coast Guard, Captain of the Port Jacksonville. [FR Doc. 2017–16177 Filed 7–31–17; 8:45 am] BILLING CODE 9110–04–P DEPARTMENT OF VETERANS AFFAIRS 38 CFR Part 4 RIN 2900–AP88 Schedule for Rating Disabilities; Musculoskeletal System and Muscle Injuries Department of Veterans Affairs. Proposed rule. AGENCY: ACTION: The Department of Veterans Affairs (VA) proposes to revise the regulations that involve the Musculoskeletal System within the VA SUMMARY: PO 00000 Frm 00031 Fmt 4702 Sfmt 4702 35719 Schedule for Rating Disabilities (‘‘VASRD’’ or ‘‘Rating Schedule’’). VA proposes to rename certain diagnostic codes, revise rating criteria, give new rating guidance, add new codes, and remove obsolete codes. These revisions would incorporate medical terminology more recent than the last comprehensive review, as well as simplify the rating process. DATES: Comments must be received by VA on or before October 2, 2017. ADDRESSES: Written comments may be submitted through www.Regulations.gov; by mail or handdelivery to Director, Regulations Management (00REG), Department of Veterans Affairs, 810 Vermont Ave. NW., Room 1068, Washington, DC 20420; or by fax to (202) 273–9026. (This is not a toll-free number.) Comments should indicate that they are submitted in response to ‘‘RIN 2900– AP88—Schedule for Rating Disabilities; Musculoskeletal System and Muscle Injuries.’’ Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 461–4902 for an appointment. (This is not a toll-free number.) In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at www.Regulations.gov. FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Regulations Staff (211C), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 461– 9700. (This is not a toll-free number.) SUPPLEMENTARY INFORMATION: The National Defense Authorization Act of 2004, secs. 1501–07, Public Law 108– 136, 117 Stat. 1392, established the Veterans’ Disability Benefits Commission (the ‘‘Commission’’). Section 1502 of Public Law 108–136 mandated the Commission to study ways to improve the disability compensation system for military veterans. The Commission consulted with the Institute of Medicine (IOM) to review the medical aspects of current compensation policies. In 2007, the IOM released its report titled ‘‘A 21st Century System for Evaluating Veterans for Disability Benefits.’’ (Michael McGeary et al. eds.2007). The IOM report was notable in several respects. The IOM observed that, in part, the Rating Schedule was inadequate in areas because it contained obsolete information and did not E:\FR\FM\01AUP1.SGM 01AUP1 35720 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules mstockstill on DSK30JT082PROD with PROPOSALS sufficiently integrate current and accepted diagnostic procedures. In addition, the IOM observed that the current body system organization of the Rating Schedule does not reflect current knowledge of the relationships between conditions and comorbidities. Following the release of the IOM report, VA created a musculoskeletal system workgroup. The goals adopted by the workgroup were to: (1) Improve and update the process that VA uses to assign levels of disability after it grants service connection; (2) improve the fairness in adjudicating disability benefits for service-connected veterans; and (3) invite public participation. The workgroup was co-chaired by the Veterans Health Administration and Veterans Benefits Administration. The workgroup was comprised of subject matter experts from VA, the Department of Defense, and medical academia. The workgroup held a public forum in Washington, DC, during August 2010, where it discussed current regulations and possible revisions. The workgroup held a second public forum in Washington, DC, during June 2012, where it shared a draft proposal for comment. The workgroup met periodically during and after the public forums to continue its revision efforts. The regulation-drafting phase, which began in April 2012, continues through the publication of this proposed rule. With this rulemaking, VA proposes to remove obsolete diagnostic codes, modernize the names of selected diagnostic codes, revise descriptions and criteria, and add new diagnostic codes. The Focus of This Revision Consistent with the IOM’s recommendations, the proposed amendments rename conditions to reflect current medicine, remove obsolete conditions, clarify ambiguities in existing rating criteria, and add conditions that previously did not have diagnostic codes. However, VA experienced greater difficulty revising existing rating criteria in many areas. After significant time and research, since an earnings loss study had not been conducted in time to be considered during the workgroup and rule-drafting phases, VA concluded there was only a narrow set of circumstances where the medical literature clearly supported the proposed changes in the absence of earnings loss information. As such, VA modified the approach recommended by the IOM for this body system. Only peer-reviewed articles where at least one measureable proxy for reduced earnings capacity was studied were deemed acceptable to VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 justify a reduction in the level or duration of ratings for specific conditions (e.g., time to return to work, activity limitations related to work, and/ or participation restriction(s) from workrelated tasks). Therefore, at this time, VA proposes changes to only two codes (diagnostic codes 5054 and 5055) where the criteria changes would result in such a reduction. I. Proposed Changes to § 4.71a A. Nomenclature Changes to Existing Diagnostic Codes: 5003, 5012–15, 5023, 5024 and 5242 In its review of the musculoskeletal body system, VA identified a number of diagnostic codes (DCs) with terms that are outdated or unclear. As such, it proposes to retitle these DCs to reflect current medical practice and nomenclature. There are no proposed substantive changes to the rating criteria for these eight DCs. VA proposes to retitle DC 5003, currently ‘‘Arthritis, degenerative (hypertrophic or osteoarthritis)’’ as ‘‘Degenerative arthritis, other than posttraumatic.’’ No other language or criteria changes are proposed for this diagnostic code. Current DCs 5012 and 5015 refer to ‘‘Bones, new growths of, malignant’’ and ‘‘Bones, new growths of, benign,’’ respectively. VA proposes to replace the term ‘‘new growths of’’ in these DCs with the current medical term, ‘‘neoplasm.’’ See S. Terry Canale and James H. Beaty, Campbell’s Operative Orthopedics 859–86 (benign) and 909– 45 (malignant) (12th ed. 2013). DC 5012 would be titled ‘‘Bones, neoplasm, malignant, primary or secondary’’ to indicate that both primary and secondary neoplasms are rated under this DC to ensure consistent and accurate evaluation. Non-substantive revisions to the language in the note under DC 5012 are also proposed; specifically, VA proposes to add the term ‘‘prescribed’’ to the phrase ‘‘therapeutic procedure’’ to ensure that readers understand VA will only consider medically-directed therapy when rating DC 5012. VA proposes to rename DC 5013, which refers to ‘‘Osteoporosis, with joint manifestations,’’ as ‘‘Osteoporosis, residuals of.’’ VA proposes a similar revision to current DC 5014 by renaming ‘‘Osteomalacia’’ as ‘‘Osteomalacia, residuals of.’’ Both osteoporosis and osteomalacia, in and of themselves, do not have any disabling characteristics. See Kelley’s Textbook of Rheumatology 1730–1750 (Gary S. Firestein and Ralph C. Budd et al. eds.,10th ed. 2017). Rather, it is the residuals of these PO 00000 Frm 00032 Fmt 4702 Sfmt 4702 conditions that VA evaluates. Thus, adding the reference ‘‘residuals of’’ provides more accurate instruction and information to rating personnel. Current DC 5023 refers to ‘‘Myositis ossificans.’’ VA proposes to update this DC to reflect the latest medical terminology and rename DC 5023 as ‘‘Heterotopic ossification.’’ See Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain and Rehabilitation, 691– 95 (Walter R. Frontera and Julie K. Silver et al. eds., 2d ed. 2008). Additionally, VA proposes to revise DC 5024, currently named, ‘‘Tenosynovitis,’’ to ‘‘Tenosynovitis, tendinitis, tendinosis, or tendinopathy.’’ These newly-added conditions are commonly seen in the veteran population and represent similar forms of disability. See Kelley’s Textbook of Rheumatology, supra at 587–604. This update would assist rating personnel in more quickly identifying the appropriate DC. Non-substantive revisions to the criteria of DC 5024 are also proposed. Finally, VA proposes to retitle DC 5242, ‘‘Degenerative arthritis of the spine’’ as ‘‘Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome.’’ This change gives rating personnel clear guidance whenever they encounter a diagnostic imaging report that references degenerative disc disease without mention of intervertebral disc syndrome (also known as disc herniation). A non-substantive revision to the citation accompanying DC 5242 is also proposed. B. Substantive Revisions to Existing Diagnostic Codes: 5002, 5009–5011, 5051–5056, 5120, 5160, 5170, 5201, 5202, 5255, 5257, 5262, and 5271 In addition to modernizing the names of certain DCs, VA also proposes substantive (i.e., not related to nomenclature) revisions to a number of existing DCs, to include some instances of changes in the evaluation criteria. 1. Diagnostic Code 5002 The first substantive revision proposed for § 4.71a involves DC 5002, ‘‘Arthritis rheumatoid (atrophic) As an active process.’’ VA proposes to retitle this code as ‘‘Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process.’’ VA proposes this change to include a greater number of systemic arthritis processes that cause multisystem effects besides rheumatoid arthritis. The title would employ the phrase ‘‘multi-joint’’ rather than ‘‘polyarthritis’’ because polyarthritis requires 4 or more joints to E:\FR\FM\01AUP1.SGM 01AUP1 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules be involved. VA would provide, in Note (1), a non-exhaustive list of conditions rated under this code (rheumatoid arthritis, psoriatic arthritis, spondyloarthropathies, etc.). See Kelley’s Textbook of Rheumatology, supra at 615–616. VA would also remove the language currently in DC 5002 regarding chronic residuals and, in Note (2), provide a directive to rate chronic residuals under DC 5003. VA proposes this change because the current language used for chronic residuals in DC 5002 is very similar to DC 5003 and its removal would simplify the schedule. Finally, VA would redesignate the code’s current note as Note (3) and add a prohibition that prevents combining ratings from active process with DC 5003, instead directing rating personnel to assign the higher evaluation. mstockstill on DSK30JT082PROD with PROPOSALS 2. Diagnostic Code 5009 VA proposes that diagnostic code 5009, currently titled ‘‘Arthritis, other types (specify),’’ be retitled as ‘‘Other specified forms of arthropathy (excluding gout).’’ VA proposes this change to capture other disease processes that cause joint injury, but are not necessarily captured within the rating schedule. The current language accompanying DC 5009, concerning how to rate diagnostic codes 5004–5009, would be redesignated as Note (2) and would be revised to give guidance on how to rate both acute phase and chronic residuals. A new Note (1) would provide a non-exhaustive list of conditions that should be rated under this diagnostic code. No other changes are proposed for this code. 3. Diagnostic Code 5010 Diagnostic code 5010 currently states: ‘‘Arthritis, due to trauma, substantiated by X-ray findings: Rate as arthritis, degenerative.’’ VA proposes to change the title and criteria to ‘‘Post-traumatic arthritis: Rate as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25.’’ VA proposes the title change to distinguish between joint conditions arising from traumatic causes and joint conditions resulting from systemic processes. This distinction is important, as the natural history (and ultimately the severity of disability) differs between joint conditions stemming from trauma as opposed to joint conditions related to systemic processes. VA proposes the change in criteria to provide a more accurate approach to rating joint injuries resulting from trauma. The trauma process is a VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 different event for each affected joint, as opposed to a condition such as rheumatoid arthritis, where the same systemic process can affect more than one joint in the same manner. VA also proposes the directive to combine ratings for separate joints affected by traumatic injury in accordance with § 4.25 so there will be no misunderstanding for rating personnel when encountering this situation. It is important to note that, as a result of these changes, DC 5010 would no longer rate joints affected by trauma-related arthritis under the criteria of DC 5003. 4. Diagnostic Code 5011 The next proposed substantive revision to § 4.71a is DC 5011, currently named ‘‘Bones, caisson disease of.’’ VA proposes to first revise the title of this DC to ‘‘Decompression illness’’ to ensure use of the most modern terminology. See Richard D. Vann et al., ‘‘Decompression Illness,’’ 377 Lancet 153–64 (2010). VA also proposes to revise the rating criteria for DC 5011, which currently direct rating personnel to ‘‘Rate as arthritis, cord involvement, or deafness, depending on the severity of disabling manifestations.’’ The proposed changes would provide more detailed instructions on how to rate manifestations associated with decompression illness that are outside of the musculoskeletal system (i.e., not arthritic). It is well established among medical experts that the most common residual manifestations from decompression illness involve the vestibule-cochlear system (e.g., hearing impairment, dizziness, vertigo), respiratory system (e.g., obstructive lung disease, pulmonary blebs) or neurologic system (e.g., peripheral neuropathy, stroke, paralysis). As such, VA proposes to direct rating personnel to consider evaluations within the auditory system for vestibular residuals, the respiratory system for pulmonary barotrauma residuals, and the neurologic system for cerebrovascular accident residuals. Id. 5. Diagnostic Codes 5051–5056 Since the last revision to the musculoskeletal system schedule, the medical community has been employing a new treatment approach, joint resurfacing, for selected joints (particularly the hip and knee). There are important similarities between joint resurfacing and prosthetic joint replacement. Joint resurfacing takes about the same time to perform and the recovery/rehabilitation periods are similar to comparable prosthetic joint replacement. This means that the impact on earnings capacity caused by the convalescence and rehabilitation PO 00000 Frm 00033 Fmt 4702 Sfmt 4702 35721 from joint resurfacing is comparable to prosthetic joint replacement. However, there are significant differences with joint resurfacing, including: (1) Joint resurfacing preserves more of the original anatomy; and, (2) in most cases, joint resurfacing restores more of the original joint function than the prosthetic joint replacement. Therefore, less residual disability typically results from joint resurfacing as compared to prosthetic joint replacement. Currently, VA does not compensate for the disability associated with joint resurfacing, despite the similar impact on earnings capacity as prosthetic joint replacement. To rectify this disparity, VA proposes to incorporate joint resurfacing within DCs 5054 and 5055 (hip and knee replacement, respectively), since more research assessing convalescence, rehabilitation, and functional recovery concerns these two joints. The DC titles would be revised to incorporate resurfacing, and the 100 percent evaluation for prosthetic hip and knee replacement would also apply to resurfacing these two joints. However, after the 100 percent evaluation period ends, further evaluation would assess the limitation of motion DCs for the hip and knee, rather than the prosthetic joint replacement of either the hip or knee, because, as previously stated, there is less of an expectation of residual disability with joint resurfacing. A note would be added to DCs 5054 and 5055 directing rating personnel, at the conclusion of the 100 percent evaluation period, to evaluate hip joint resurfacing claims under DCs 5250–5255 and knee joint resurfacing claims under DCs 5256–5262. VA currently evaluates total joint replacements by assigning a 100 percent evaluation for 1 year following implantation of a prosthesis. After 1 year, VA assigns a minimum evaluation, with higher evaluations for complications or residuals such as weakness, pain, and limitation of motion. The evaluations assigned under these DCs are intended to encompass all musculoskeletal residuals under § 4.71a. Separate evaluations may be assigned for residuals such as scars or neurological deficits pursuant to § 4.14. VA proposes two modifications in this regard. First, a note prior to DCs 5051 to 5056 would clarify that separate evaluations may not be assigned under § 4.71a for the joint that was resurfaced or replaced by a prosthesis unless otherwise directed. This note is intended to clarify current practice and ensure consistent application of these DCs among rating personnel. E:\FR\FM\01AUP1.SGM 01AUP1 35722 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules In addition, for DCs 5054 and 5055, VA proposes to reduce the 100 percent evaluation period from 1 year to 4 months. Current medical practice for these conditions has recovery timelines that in most cases permit return to work well short of 1 year. In a review of studies looking at factors affecting return to work, the average time for return to work was between 1.1 and 13.9 weeks for hip arthroplasty and between 8.0 and 12.0 weeks for knee arthroplasty. See Claire Tilbury et al., ‘‘Return to work after total hip and knee arthroplasty: a systematic review,’’ 53 Rheumatology 512–525 (2014). mstockstill on DSK30JT082PROD with PROPOSALS 6. Diagnostic Code 5120 VA currently evaluates amputations of the arm that involve disarticulation under DC 5120 as 90 percent disabling regardless of dominant arm involvement At the outset, VA proposes to revise the name of this DC to ‘‘Complete amputation, upper extremity,’’ as this is a more accurate description of the amputation level and site. Second, VA proposes to create two levels of disability under DC 5120 for rating purposes. One level would be titled ‘‘Disarticulation (involving complete removal of the humerus only)’’ and would provide a 90 percent compensation level for either major or minor extremity involvement; this level would be consistent with the current compensation level under DC 5120. However, the second level, to be titled ‘‘Forequarter amputation (involving complete removal of the humerus along with any portion of the scapula, clavicle, and/or ribs),’’ would provide for 100 percent compensation for either dominant or non-dominant extremity involvement. See Canale, supra at 659– 71. Although both levels represent complete amputation of the upper extremity, VA believes a higher level of compensation is warranted for forequarter amputation because it is a more extensive amputation than disarticulation and results in a more significant occupational impact. 7. Diagnostic Code 5160 For reasons similar to those discussed immediately above, VA proposes two revisions of DC 5160, which pertains to amputation of the thigh at the level of disarticulation with loss of extrinsic pelvic girdle muscles. First, VA proposes to retitle this DC to ‘‘Complete amputation, lower extremity’’ to more accurately describe the amputation level and site. VA also proposes to create two levels of criteria for rating purposes. One would be titled ‘‘Disarticulation (involving complete removal of the VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 femur and intrinsic pelvic musculature only)’’ and would provide a 90 percent rating that is consistent with the current rating under DC 5160. The second level, titled ‘‘Trans-pelvic amputation (involving complete removal of the femur and intrinsic pelvic musculature along with any portion of the pelvic bones),’’ would provide for a 100 percent rating. See Canale, supra at 651– 58. VA believes that a higher level of compensation is warranted for transpelvic amputation because it is a more extensive amputation than disarticulation and results in a more significant occupational impact. VA also proposes to insert a note under DC 5160 directing rating personnel to separately evaluate residuals involving other body systems, such as bowel or bladder impairment, under the appropriate diagnostic code. 8. Diagnostic Code 5170 Current DC 5170 refers to ‘‘Toes, all, amputation of, without metatarsal loss.’’ VA proposes to add the phrase ‘‘or transmetatarsal, amputation of, with up to half of metatarsal loss’’ to include a residual of toe amputation that causes similar disability. See Canale, supra at 622–23. No change to the current level of compensation is proposed. 9. Diagnostic Code 5201 VA currently assigns ratings for limitation of motion of the arm at the shoulder where motion is limited to 25 degrees from the side, 45 degrees (midway between the side and shoulder level), or 90 degrees (at the shoulder level). VA proposes to clarify the terminology used in these criteria by adding ranges of motion of the shoulder. Specifically, VA proposes to assign a 40 percent rating for a major joint, or 30 percent for a minor joint, where flexion and/or abduction is limited to 25 degrees from the side. VA also proposes to assign a 30 percent rating for a major joint, or 20 percent for a minor joint, where motion is limited to ‘‘midway between side and shoulder level,’’ defined as flexion and/or abduction limited to 45 degrees or less. Finally, VA proposes to assign a 20 percent rating for a major or minor joint where motion is limited ‘‘at shoulder level,’’ defined as flexion and/or abduction limited to 90 degrees or less. These changes are not intended to alter the rating criteria. The proposed changes simply clarify the specific ranges of motion that qualify as limitations to ensure rating personnel consistently apply these criteria. PO 00000 Frm 00034 Fmt 4702 Sfmt 4702 10. Diagnostic Code 5202 Currently, VA assigns a 20 percent rating for either shoulder joint when there are infrequent episodes of dislocation of the humerus at the scapulohumeral joint, with guarding of movement only at the shoulder level. VA proposes to define ‘‘the shoulder level’’ as flexion and/or abduction at 90 degrees. This change is not intended to alter the rating criteria. The proposed change simply clarifies the specific ranges of motion that qualify as limitations to ensure rating personnel consistently apply these criteria. 11. Diagnostic Code 5255 VA currently evaluates malunion of the femur by assigning a 30 percent rating for a ‘‘marked knee or hip disability,’’ a 20 percent rating for a ‘‘moderate knee or hip disability,’’ and a 10 percent rating for a ‘‘slight knee or hip disability.’’ These criteria are subjective and the terminology is vague, resulting in inconsistent ratings. Therefore, VA proposes removing this terminology and replacing it with an instruction to rate malunion of the femur as a knee or hip disability, whichever is predominant, under existing DCs that contain objective criteria. Specifically, this condition may be rated under DCs 5256 (Knee, ankylosis of), 5257 (Knee, other impairment of), 5260 (Leg, limitation of flexion of), 5261 (Leg, limitation of extension of), 5250 (Hip, ankylosis of), 5251 (Thigh, limitation of extension of), 5252 (Thigh, limitation of flexion of), 5253 (Thigh, impairment of), or 5254 (Hip, flail joint). This change would ensure that rating personnel consistently evaluate this disability based on objective criteria. 12. Diagnostic Code 5257 VA currently assigns ratings for recurrent subluxation or lateral instability of the knee based on whether the condition is slight (10 percent), moderate (20 percent), or severe (30 percent). These criteria are subjective and the terminology is vague, resulting in VA assigning inconsistent ratings. When the condition involves patellar instability of the knee (due to recurrent patellar subluxation or patellar dislocation), one can determine the severity of functional impairment in large part by 1) the presence, or absence of, anatomic abnormalities (e.g., direct damage to patellofemoral ligament complex, ‘‘flake’’ fractures, or abnormalities affecting the patella and/ or femoral trochlea); and 2) whether conservative treatment prevents recurrent instability. See Alexis C. E:\FR\FM\01AUP1.SGM 01AUP1 mstockstill on DSK30JT082PROD with PROPOSALS Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules Colvin and Robin V. West, ‘‘Current Concepts Review: Patellar Instability,’’ J. Bone & Joint Surgery—Am. Volume 90: 2751–62 (2008). Instability or laxity of the knee that involves other stabilizing structures of the knee such as the collateral ligaments (medial or lateral) or the cruciate ligaments (anterior or posterior) are given a ‘‘grade’’ depending upon the amount of translation, in millimeters, of the joint (e.g., a grade 1 injury of the posterior cruciate ligament (PCL) is represented by 0 to 5 millimeters (mm) of translation). T. K. Kakarlapudi et al., ‘‘Knee instability: isolated and complex,’’ 34 Br. J. Sports Med. 395–400 (2000). Resulting functional impairment depends upon the grade of the injury and whether surgical intervention is required. Id. The higher the number grade is, the more severe the injury; that is, grade 1 would represent the least severe injury, grade 2 would be a more severe injury, and grade 3 would be the most severe injury. Therefore, VA proposes replacing the current subjective terms with the following objective criteria: a 30 percent rating would be assigned for persistent grade 3 instability despite operative intervention and for which ambulation requires both bracing and an assistive device (e.g., cane(s), crutch(es), or a walker), as prescribed by a physician; or, in the case of patellar instability, persistent instability despite surgical repair (whether after the primary subluxation/dislocation event or due to recurrent instability). A 20 percent would be assigned for persistent grade 3 instability without operative intervention, but when ambulation requires both bracing and an assistive device (e.g., cane(s), crutch(es), or a walker), as prescribed by a physician; or, in the case of patellar instability, recurrent instability persists due to one or more documented underlying anatomic abnormalities, without surgical repair. A 10 percent evaluation would be assigned for persistent grade 1, 2, or 3 instability which requires an ambulation assistive device or bracing, as prescribed by a physician; or, in the case of patellar instability, recurrent instability persists without documented underlying anatomic abnormalities, without surgical repair. These criteria would take into account both the grade of the injury, as well as functional impairment resulting from the injury. VA also proposes a note defining the grading of instability. Note (1) would specify that grade 1 instability requires 0–5 mm of joint translation, while grade 2 requires translation of 6–10 mm, and grade 3 requires joint translation equal to or greater than 11 mm. These levels VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 of instability or laxity are based upon modern medical practice. See Campbell’s Operative Orthopedics, supra at 2157. VA proposes a second note to clarify what constitutes surgical repair of patellar instability. Note (2) would specify that any operative procedure which does not involve actual anatomical structural repair would not qualify as surgical repair for the purposes of compensation. This note is specifically designed to exclude procedures that are not designed to repair instability or subluxation, such as joint aspiration, arthroscopy to remove loose bodies, and so forth. In addition, DC 5257 currently refers to ‘‘lateral instability.’’ Under current practice, any instability or laxity of the knee is evaluated under this code. Therefore, VA proposes to remove the term ‘‘lateral,’’ so that this code also encompasses other specified forms of instability and/or laxity. 13. Diagnostic Code 5262 VA currently rates malunion of the tibia and fibula by assigning a 30 percent rating for a ‘‘marked knee or ankle disability,’’ a 20 percent rating for a ‘‘moderate knee or ankle disability,’’ and a 10 percent rating for a ‘‘slight knee or ankle disability.’’ These criteria are subjective and the terminology is vague. This results in rating personnel assigning inconsistent ratings under these criteria. Therefore, VA proposes removing this terminology and replacing it with an instruction to rate malunion of the tibia or fibula as a knee or ankle disability, whichever is predominant, under existing DCs that contain objective criteria. Specifically, this condition may be evaluated under DCs 5256 (Knee, ankylosis of), 5257 (Knee, other impairment of), 5260 (Leg, limitation of flexion of), 5261 (Leg, limitation of extension of), 5270 (Ankle, ankylosis of), or 5271 (Ankle, limited motion of). This change would ensure that rating personnel consistently assign evaluations based on objective criteria. Another condition commonly claimed for disability compensation is medial tibial stress syndrome (MTSS), also known as ‘‘shin splints.’’ It is a benign but painful condition that is typically diagnosed simply by history and physical examination, though imaging studies such as plain radiographs, bone scans, or magnetic resonance imaging (MRI) can be used in borderline cases, as well as to diagnose other conditions. The vast majority of cases respond to conservative therapy, such as rest, shock-absorbing insoles, and electrowave shock therapy. The rare PO 00000 Frm 00035 Fmt 4702 Sfmt 4702 35723 persistent cases that do not respond to conservative treatment can be treated with surgical intervention. To that end, VA proposes to modify the criteria for DC 5262 to account for MTSS as well as associated conditions. See M. Reshef and D. Guelich, ‘‘Medial Tibial Stress Syndrome,’’ 31 Clinical Sports Med. 273–90 (2012). 14. Diagnostic Code 5271 VA currently assigns ratings for limited motion of the ankle depending upon whether the limitation is moderate (10 percent) or marked (20 percent). These criteria are subjective and the terminology is vague, resulting in inconsistent evaluations. Therefore, VA proposes to define marked limitation of motion as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. VA also proposes to define moderate limitation of motion as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. As VA currently uses these standards to define marked and moderate, this change is intended as a clarification of current policy and would ensure consistent application of these criteria among rating personnel. C. Proposed New Diagnostic Codes 1. Diagnostic Code 5244 The current Rating Schedule does not provide instructions for rating complete traumatic paralysis, i.e., paraplegia or quadriplegia; however, this disability is not uncommon in the veteran population. As such, VA proposes the addition of DC 5244, ‘‘Traumatic paralysis, complete.’’ The proposed criteria for DC 5244 would direct personnel to rate paraplegia, or functional loss of the lower limbs and trunk, under DC 5110. DC 5110 applies to loss of use of both feet and provides for a 100 percent disability rating with entitlement to special monthly compensation. Proposed DC 5244 would also provide instructions for rating quadriplegia, or paralysis of all four limbs (i.e., the entire body below the neck). Specifically, VA proposes to rate quadriplegia under both DC 5109, loss of use of both hands, and DC 5110, loss of use of both feet, and combine. In practice, a veteran with service-connected quadriplegia would be entitled to two 100 percent ratings, which combine under 38 CFR 4.25 to a total evaluation of 100 percent. The veteran would also be entitled to special monthly compensation. 2. Diagnostic Code 5285 VA currently evaluates foot injuries not specifically listed in § 4.71a under E:\FR\FM\01AUP1.SGM 01AUP1 mstockstill on DSK30JT082PROD with PROPOSALS 35724 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules DC 5284 as ‘‘Foot injuries, other.’’ Plantar fasciitis, a foot disability seen in the veteran population, is generally rated under this DC. However, unlike other unlisted foot injuries and conditions, which can often result in a variety of signs and symptoms with varying degrees of disability, plantar fasciitis, and its functional effects, are very well defined. See Sports Medicine and Arthroscopic Surgery of the Foot and Ankle 83–93 (Amol Saxena ed., 2013). Plantar fasciitis, also known as ‘‘jogger’s heel,’’ is generally characterized by heel pain due to inflammation. Craig C. Young et al., ‘‘Plantar fasciitis,’’ Medscape Reference (Feb. 4, 2014), https:// emedicine.medscape.com/article/86143overview (last visited April 15, 2014). However, even at its most severe, this condition involves an otherwise structurally intact foot. There are a variety of both surgical and non-surgical treatments that may relieve the primary symptoms of plantar fasciitis. Conservative measures are always employed first, and frequently include icing, stretching, non-steroidal anti-inflammatory drug (NSAID) therapy, strapping and taping, and/or over-the-counter orthotics. Id. at https:// emedicine.medscape.com/article/86143treatment. Other nonsurgical treatments may include injections, physical therapy, and custom orthotics. Id. Studies have reported a resolution incidence of up to 90 percent with nonsurgical measures. Id. In severe cases, non-surgical measures fail and surgery is required. Individuals who respond to treatment, whether surgical or non-surgical, have generally no more than slight functional limitation due to plantar fasciitis. Further, such limitation is more associated with the treatment(s) required to check the pain (e.g., limitation of physical activities (such as running), injections, icing, use of NSAIDS, surgical residuals, etc.) than with the actual disability itself. For individuals who do not respond to treatment, the resulting limitations may vary, but are generally more pronounced for those who have bilateral, rather than unilateral, plantar fasciitis. Given the foregoing, VA proposes to create a new DC, namely DC 5285, ‘‘Plantar fasciitis,’’ to rate this condition. VA intends to evaluate this disability based on a combination of extent (one foot or both feet) and response to treatment (responsive or nonresponsive). For individuals whose plantar fasciitis does not respond to both surgical and non-surgical treatment, VA proposes to award 30 percent disability rating if both feet are VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 affected and a 20 percent disability rating if one foot is affected. For an individual whose plantar fasciitis (either unilateral or bilateral) is responsive to treatment (either nonsurgical or surgical), VA proposes a 10 percent disability rating. Finally, consistent with other foot injuries and disabilities, VA intends to include a note with DC 5285 that would instruct rating personnel to assign a 40 percent rating in cases where there is actual loss of use of the foot. In cases where a veteran’s bilateral plantar fasciitis has not improved following surgery and there is actual loss of use of one foot, this would result in a 40 percent evaluation for that foot and a 20 percent evaluation for the other foot that was not responsive to treatment, but did not result in loss of use. D. Removal of Existing Diagnostic Codes VA proposes to remove three obsolete codes from § 4.71a. The first two, DC 5018 and DC 5020, refer to ‘‘Hydrarthrosis, intermittent’’ and ‘‘Synovitis,’’ respectively. Both hydrarthrosis and synovitis are signs found on physical examination. The disability from a specific condition that causes either hydrarthrosis or synovitis (e.g., rheumatoid arthritis, psoriatic arthritis, or pseudogout) is captured within current evaluation criteria for the specific disabling condition. See Kelley’s Textbook of Rheumatology, supra at 588. Given that VA’s disability compensation system is designed to compensate for disabilities, it is not appropriate to list either sign as its own DC. For similar reasons, VA proposes to remove DC 5022, ‘‘Periostitis.’’ Current medical terminology refers to ‘‘periosteal reaction’’ in order to include all of the possible causes, such as bleeding, infection, or tumor. In contrast, ‘‘periostitis’’ refers to a nonspecific inflammatory process due to a number of diagnoses that could potentially result in service connection. Since an evaluation should be conducted under the primary diagnosis, rather than a radiographic finding such as periostitis, VA intends to remove DC 5022. See Radiologic-Pathologic Correlations from Head to Toe: Understanding the Manifestations of Disease 668 (Nicholas C. Gourtsoyiannis and Pablo R. Ros eds., 2005). II. Proposed Changes to § 4.73 Section 4.73 provides VA’s schedule for rating muscle injuries. Following its review of this body system, VA proposes the addition of two DCs for conditions that previously required analogous rating. PO 00000 Frm 00036 Fmt 4702 Sfmt 4702 The first proposed code, DC 5330, would apply to residuals of rhabdomyolysis, in which muscle tissue breaks down rapidly. See Janice L. Zimmerman and Michael C. Shen, ‘‘Rhabdomyolysis,’’ 144(3) CHEST 1058–65 (2013). Although VA proposes to rate this condition based on residual impairment to the affected muscle group(s), it believes that a specific DC is needed as there is no current instruction to rating personnel as to how to evaluate this condition. Furthermore, in addition to provide rating instructions to evaluate each affected muscle group, VA proposes to include a note directing rating personnel to separately evaluate any chronic renal complications that may be associated with this condition. The second DC VA proposes to add to § 4.73 is DC 5331, ‘‘Compartment syndrome.’’ Similar to DC 5330, VA proposes to rate compartment syndrome, a condition in which there is increased pressure within the muscles, according to the affected muscle group(s). See Canale, supra at 2311–21. The addition of this DC would provide clear instructions to rating personnel; it would also eliminate the need for analogous coding for a condition seen in the veteran population. In addition, VA proposes to add a second note at the beginning of § 4.73 directing that rating personnel consider the objective criteria contained in § 4.56 when determining whether a muscle disability is slight, moderate, moderately severe, or severe under DCs 5301 to 5323. Although § 4.56 references these DCs, the levels of severity are not defined in § 4.73, nor does that section currently reference § 4.56. Therefore, VA proposes to add this note for a crossreference. Executive Orders 12866 and 13563 Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 (Regulatory Planning and Review) defines a ‘‘significant regulatory action,’’ which requires review by the Office of Management and Budget (OMB), as ‘‘any regulatory action that is likely to result in a rule that may: E:\FR\FM\01AUP1.SGM 01AUP1 35725 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules (1) Have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) Create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) Materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) Raise novel legal or policy issues arising out of legal mandates, the President’s priorities, or the principles set forth in this Executive Order.’’ VA has examined the economic, interagency, budgetary, legal, and policy implications of this proposed rule, and it has been determined not to be a significant regulatory action under Executive Order 12866. VA’s impact analysis can be found as a supporting document at https:// www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of the rulemaking and its impact analysis are available on VA’s Web site at https:// www1.va.gov/orpm/, by following the link for ‘‘VA Regulations Published.’’ Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This proposed rule would have no such effect on State, local, and tribal governments, or on the private sector. Paperwork Reduction Act Signing Authority Although this document contains provisions constituting a collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. 3501 et seq.), no new or proposed revised collections of information are associated with this proposed rule. The information collection requirements are currently approved by the Office of Management and Budget (OMB) and have been assigned OMB control numbers 2900–0747, 2900–0776, 2900– 0778, and 2900–0802 through 2900– 0813. While no modifications to these forms are made by this rulemaking, the total incremental cost to all respondents is estimated to be $198,002.21 during the first year. See Regulatory Impact Analysis for a full explanation. The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Gina S. Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, approved this document on June 20, 2017, for publication. Regulatory Flexibility Act The Secretary hereby certifies that this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601–612. This proposed rule would not affect any small entities. Only VA beneficiaries could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this proposed rule would be exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604. Catalog of Federal Domestic Assistance Numbers and Titles The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.013, Veterans Prosthetic Appliances; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death. Dated: July 21, 2017. Michael Shores, Director, Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs. List of Subjects in 38 CFR Part 4 Disability benefits, Pensions, Veterans. For the reasons set out in the preamble, VA proposes to amend 38 CFR part 4 as follows: PART 4—SCHEDULE FOR RATING DISABILITIES Subpart B—Disability Ratings 1. The authority citation for part 4, subpart B continues to read as follows: ■ Authority: 38 U.S.C. 1155, unless otherwise noted. 2. Amend § 4.71a as follows: a. Revise diagnostic codes 5002, 5003, 5009–5015, 5023–5024, 5054, 5055, 5120, 5160, 5170, 5201, 5202, 5242, 5255, 5257, 5262, and 5271. ■ b. Remove diagnostic codes 5018, 5020, and 5022. ■ c. Add new introduction note to diagnostic codes 5051 through 5056 and add new diagnostic codes 5244 and 5285. The revisions and additions read as follows: ■ ■ § 4.71a Schedule of ratings— musculoskeletal system. ACUTE, SUBACUTE, OR CHRONIC DISEASES Rating mstockstill on DSK30JT082PROD with PROPOSALS 5002 * * * * * Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process: * * * * * * * One or two exacerbations a year in a well-established diagnosis ............................................................................................... Note (1): Examples of conditions rated using this diagnostic code include, but are not limited to, rheumatoid arthritis, psoriatic arthritis, and spondyloarthropathies. Note (2): For chronic residuals, rate under diagnostic code 5003. Note (3): The ratings for the active process will not be combined with the residual ratings for limitation of motion, ankylosis, or diagnostic code 5003. Instead, assign the higher evaluation. 5003 Degenerative arthritis, other than post-traumatic: 5009 * * * Other specified forms of arthropathy (excluding gout). VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 PO 00000 Frm 00037 * Fmt 4702 * Sfmt 4702 E:\FR\FM\01AUP1.SGM * 01AUP1 * * 20 * 35726 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules ACUTE, SUBACUTE, OR CHRONIC DISEASES—Continued Rating Note (1): Other specified forms of arthropathy include, but are not limited to, Charcot neuropathic, hypertrophic, crystalline, and other autoimmune arthropathies. Note (2): With the types of arthritis, diagnostic codes 5004 through 5009, rate the acute phase under diagnostic code 5002; rate any chronic residuals under diagnostic code 5003. 5010 Post-traumatic arthritis: Rate as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. 5011 Decompression illness: Rate manifestations under the appropriate diagnostic code within the affected body system, such as arthritis for musculoskeletal residuals; auditory system for vestibular residuals; respiratory system for pulmonary barotrauma residuals; and neurologic system for cerebrovascular accident residuals. 5012 Bones, neoplasm, malignant, primary or secondary ............................................................................................................... Note: The 100 percent rating will be continued for 1 year following the cessation of surgical, X-ray, antineoplastic chemotherapy or other prescribed therapeutic procedure. If there has been no local recurrence or metastases, rate based on residuals. 5013 Osteoporosis, residuals of. 5014 Osteomalacia, residuals of. 5015 Bones, neoplasm, benign. * * * * * * 5023 Heterotopic ossification. 5024 Tenosynovitis, tendinitis, tendinosis or tendinopathy. Evaluate the diseases under diagnostic codes 5013 through 5024 as degenerative arthritis, based on limitation of motion of affected parts. However, evaluate gout under diagnostic code 5003. * * * * * * 100 * * PROSTHETIC IMPLANTS AND RESURFACING Rating Major Minor Note: When an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under diagnostic codes 5051–5056, an additional rating under § 4.71a may not also be assigned for that joint, unless otherwise directed. * * * * * 5054 Hip, resurfacing or replacement (prosthesis) Prosthetic replacement of the head of the femur or of the acetabulum: For 4 months following implantation of prosthesis or resurfacing .................................................................... Note: At the conclusion of the 100 percent evaluation period, evaluate resurfacing under diagnostic codes 5250 through 5255. * * * * * 5055 Knee, resurfacing or replacement (prosthesis) Prosthetic replacement of knee joint: For 4 months following implantation of prosthesis or resurfacing .................................................................... Note: At the conclusion of the 100 percent evaluation period, evaluate resurfacing under diagnostic codes 5256 through 5262. * * * * * * * ........................ * 100 * ........................ * 100 * AMPUTATIONS: UPPER EXTREMITY Rating mstockstill on DSK30JT082PROD with PROPOSALS Major Arm, amputation of: 5120 Complete amputation, upper extremity: Forequarter amputation (involving complete removal of the humerus along with any portion of the scapula, clavicle, and/or ribs) ................................................................................................................ Disarticulation (involving complete removal of the humerus only) ............................................................ * * * * * Minor 100 90 * 100 90 * AMPUTATIONS: LOWER EXTREMITY Rating Thigh, amputation of: VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 PO 00000 Frm 00038 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 35727 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules AMPUTATIONS: LOWER EXTREMITY—Continued Rating 5160 Complete amputation, lower extremity Trans-pelvic amputation (involving complete removal of the femur and intrinsic pelvic musculature along with any portion of the pelvic bones) .................................................................................................................................................... Disarticulation (involving complete removal of the femur and intrinsic pelvic musculature only) ........................................ Note: Separately evaluate residuals involving other body systems (e.g., bowel impairment, bladder impairment) under the appropriate diagnostic code. * 5170 * * * * * Toes, all, amputation of, without metatarsal loss or transmetatarsal, amputation of, with up to half of metatarsal loss * * * * * * 100 90 * 30 * THE SHOULDER AND ARM Rating Major * * * * * 5201 Arm, limitation of motion of: Flexion and/or abduction limited to 25° from side ............................................................................................ Midway between side and shoulder level (flexion and/or abduction limited to 45°) ........................................ At shoulder level (flexion and/or abduction limited to 90°) .............................................................................. 5202 Humerus, other impairment of: Loss of head of (flail shoulder) ......................................................................................................................... Nonunion of (false flail joint) ............................................................................................................................. Fibrous union of ................................................................................................................................................ Recurrent dislocation of at scapulohumeral joint: With frequent episodes and guarding of all arm movements .......................................................................... With infrequent episodes, and guarding of movement only at shoulder level (flexion and/or abduction at 90°) ................................................................................................................................................................ Malunion of: Marked deformity .............................................................................................................................................. Moderate deformity ........................................................................................................................................... * * * * * Minor * * 40 30 20 30 20 20 80 60 50 70 50 40 30 20 20 20 30 20 20 20 * * THE SPINE Rating General Rating Formula for Diseases and Injuries of the Spine * * * * * * 5242 Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see diagnostic code 5003). * * * * * * * 5244 Traumatic paralysis, complete: Paraplegia: Rate under diagnostic code 5110. Quadriplegia: Rate separately under diagnostic codes 5109 and 5110 and combine evaluations in accordance with § 4.25. * mstockstill on DSK30JT082PROD with PROPOSALS The Hip and Thigh * * * * * * 5255 Femur, impairment of: Fracture of shaft or anatomical neck of: With nonunion, with loose motion (spiral or oblique fracture) .............................................................................................. With nonunion, without loose motion, weight bearing preserved with aid of brace ............................................................. Fracture of surgical neck of, with false joint ......................................................................................................................... Malunion of: Evaluate under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5250–5254 for the hip, whichever results in the highest evaluation. * 80 60 60 The Knee and Leg 5257 * * Knee, other impairment of: VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 * PO 00000 * Frm 00039 Fmt 4702 * Sfmt 4702 E:\FR\FM\01AUP1.SGM * 01AUP1 * 35728 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules THE SPINE—Continued Rating Recurrent subluxation or instability: Persistent grade 3 instability despite operative intervention and a physician prescribes both bracing and assistive device (e.g., cane(s), crutch(es), or a walker) for ambulation .............................................................................................. Persistent grade 3 instability without operative intervention, and a physician prescribes both bracing and assistive device (e.g., cane(s), crutch(es), or a walker) for ambulation .............................................................................................. Persistent grade 1, 2, or 3 instability and a physician prescribes an assistive device (e.g., cane(s), crutch(es), or a walker) or bracing for ambulation ...................................................................................................................................... Patellar instability: With documented surgical repair, persistent instability either after the primary subluxation/dislocation event or due to recurrent instability ............................................................................................................................................................. Without surgical repair, recurrent instability with one or more documented underlying anatomic abnormalities (e.g., direct damage to patellofemoral ligament complex, ‘‘flake’’ fractures, or abnormalities affecting the patella and/or femoral trochlea) ...................................................................................................................................................................... Without surgical repair, recurrent instability without documented underlying anatomic abnormalities ................................ Note (1): Grade 1 is defined as 0–5 mm of joint translation, grade 2 is defined as 6–10 mm of joint translation, and grade 3 is defined as joint translation of equal to or greater than 11 mm. Note (2): For patellar instability, a surgical procedure that does not involve repair of one or more anatomic structures that contribute to the underlying instability shall not qualify as surgical repair for compensation purposes (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). * * * * * * 5262 Tibia and fibula, impairment of: Nonunion of, with loose motion, requiring brace ......................................................................................................................... Malunion of: Evaluate under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Medial tibial stress syndrome (MTSS), or shin splints: With imaging evidence (X-rays, bone scan, or MRI), requiring treatment for no less than 12 consecutive months and unresponsive to shoe orthotics, other conservative treatment, or surgery, both lower extremities ................................. With imaging evidence (X-rays, bone scan, or MRI), requiring treatment for no less than 12 consecutive months, and unresponsive to shoe orthotics, other conservative treatment, or surgery, one lower extremity ..................................... With imaging evidence (X-rays, bone scan, or MRI), requiring treatment for no less than 12 consecutive months, and unresponsive to both shoe orthotics and other conservative treatment, one or both lower extremities .......................... Treatment less than 12 consecutive months, one or both lower extremities ....................................................................... * * * * * * 30 20 10 30 20 10 * 40 30 20 10 0 * The Ankle * * * * * * 5271 Ankle, limited motion of: Marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) .................................................................... Moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) .............................................................. * * * * * * * 20 10 * The Foot * * * * * * 5285 Plantar fasciitis: With symptoms not relieved by both non-surgical and surgical treatment: bilateral .................................................................................................................................................................................. unilateral ................................................................................................................................................................................ With symptoms relieved by either non-surgical or surgical treatment, unilateral or bilateral ...................................................... Note: With actual loss of use of the foot, rate 40 percent. * 30 20 10 The Skull mstockstill on DSK30JT082PROD with PROPOSALS * * * (Authority: 38 U.S.C. 1155) * * * * * ■ 3. In § 4.73, add new introduction notes (1) and (2) and add new diagnostic codes 5330 and 5331 to read as follows: VerDate Sep<11>2014 19:43 Jul 31, 2017 Jkt 241001 * * § 4.73 Schedule of ratings—muscle injuries. Note (1): When evaluating any claim involving muscle injuries resulting in loss of use of any extremity or loss of use of both buttocks (diagnostic code 5317, Muscle PO 00000 Frm 00040 Fmt 4702 Sfmt 4702 * * Group XVII), refer to § 3.350 of this chapter to determine whether the veteran may be entitled to special monthly compensation. Note (2): Ratings of slight, moderate, moderately severe, or severe for diagnostic E:\FR\FM\01AUP1.SGM 01AUP1 35729 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules codes 5301 through 5323 will be determined based upon the criteria contained in § 4.56. * * * * * MISCELLANEOUS Rating * * * * * 5330 Rhabdomyolysis, residuals of. Rate each affected muscle group separately and combine in accordance with § 4.25. Note: Separately evaluate any chronic renal complications within the appropriate body system. 5331 Compartment syndrome. Rate each affected muscle group separately and combine in accordance with § 4.25. (Authority: 38 U.S.C. 1155) b. In § 4.71a, add diagnostic codes 5009–5011, 5013–5015, 5018, 5020, 5022–5023, 5120, 5160, 5170, 5201, 5202, 5242, 5244, 5262, 5271 and 5285; ■ c. In § 4.73, add new introduction note and diagnostic codes 5330 and 5331. * The revisions read as follows: ■ 4. Amend Appendix A to Part 4 as follows: ■ a. In § 4.71a, revise diagnostic codes 5002, 5003, 5012, 5024, 5051–5056, 5255, 5257; ■ * Appendix A to Part 4—Table of Amendments and Effective Dates Since 1946 Diagnostic Code No. Sec. 4.71a * * * 5002 5003 * * * * Evaluation March 1, 1963; title, criteria, note [insert effective date of final rule] Added July 6, 1950; title [insert effective date of final rule] * * * 5009 5010 5011 5012 5013 5014 5015 5018 5020 5022 5023 5024 * * * Title, evaluation, note [insert effective date of final rule]. Title, criteria [insert effective date of final rule]. Title, criteria [insert effective date of final rule]. Criterion March 10, 1976; title, note [insert effective date of final rule]. Title [insert effective date of final rule]. Title [insert effective date of final rule]. Title [insert effective date of final rule]. Removed [insert effective date of final rule]. Removed [insert effective date of final rule]. Removed [insert effective date of final rule]. Title [insert effective date of final rule]. Criterion March 1, 1963; title, criteria [insert effective date of final rule]. * * * 5051 5052 5053 5054 5056 * * * * Added September 22, 1978; note [insert effective date of final rule]. Added September 22, 1978; note [insert effective date of final rule]. Added September 22, 1978; note [insert effective date of final rule]. Added September 22, 1978; title, criterion, and note [insert effective date of final rule]. Added September 22, 1978; title, criterion, and note [insert effective date of final rule]. Added September 22, 1978; note [insert effective date of final rule]. 5055 * * * 5120 5160 * * * Title, criterion [insert effective date of final rule]. Title, criterion, note [insert effective date of final rule]. * * mstockstill on DSK30JT082PROD with PROPOSALS * * * 5170 * * Title [insert effective date of final rule]. * * * * * 5201 5202 * * Criterion [insert effective date of final rule]. Criterion [insert effective date of final rule]. * * * * * 5242 * * Title [insert effective date of final rule] * * * * * 5244 * * Added [insert effective date of final rule]. * * VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 PO 00000 Frm 00041 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 35730 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules Diagnostic Code No. Sec. * * * 5255 * * * Criterion July 6, 1950; criterion [insert effective date of final rule]. * * * 5257 * * * * Evaluation July 6, 1950; criterion and note [insert effective date of final rule]. * * * 5262 * * Criterion [insert effective date of final rule]. * * * * * 5271 * * Criterion [insert effective date of final rule]. * * * * * 5285 * * Added [insert effective date of final rule]. * * * * 4.73 ........................................................... * * ........................ * * 5330 5331 5. Amend Appendix B to Part 4 as follows: ■ a. Revise diagnostic codes 5002, 5003, 5009–5015, 5023, 5024, 5054, 5055, 5120, 5160, 5170 and 5242; ■ * * * * * Introduction NOTE criterion July 3, 1997; second NOTE added [insert effective date of final rule]. * * Added [insert effective date of final rule]. Added [insert effective date of final rule]. * * Appendix B to Part 4—Numerical Index of Disabilities b. Add diagnostic codes 5244, 5285, 5330, and 5331; and ■ c. Remove diagnostic codes 5018, 5020 and 5022. The revisions read as follows: ■ Diagnostic Code No. THE MUSCULOSKELETAL SYSTEM Acute, Subacute, or Chronic Diseases * * 5002 ................................................ 5003 ................................................ * * * * Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process. Degenerative arthritis, other than post-traumatic. * * * * Other specified forms of arthropathy (excluding gout). Post-traumatic arthritis. Decompression illness. Bones, neoplasm, malignant, primary or secondary. Osteoporosis, residuals of. Osteomalacia, residuals of. Bones, neoplasm, benign. * * * * 5023 ................................................ 5024 ................................................ * * Heterotopic ossification. Tenosynovitis, tendinitis, tendinosis or tendinopathy. * * * * * 5054 ................................................ 5055 ................................................ * * Hip, resurfacing or replacement (prosthesis). Knee, resurfacing or replacement (prosthesis). * * * * * * * * * 5009 5010 5011 5012 5013 5014 5015 * * ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ * * * * mstockstill on DSK30JT082PROD with PROPOSALS AMPUTATIONS: UPPER EXTREMITY Arm, amputation of: 5120 ......................................... * Complete amputation, upper extremity. * * * AMPUTATIONS: LOWER EXTREMITY Thigh, amputation of: 5160 ......................................... VerDate Sep<11>2014 17:34 Jul 31, 2017 Complete amputation, lower extremity. Jkt 241001 PO 00000 Frm 00042 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 35731 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules Diagnostic Code No. * * 5170 ......................................... * * * * * * Toes, all, amputation of, without metatarsal loss or transmetatarsal, amputation of, with up to half of metatarsal loss. * * * * * * SPINE * * 5242 ................................................ * * * * * Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either 5003 or 5010). * * 5244 ................................................ * Traumatic paralysis, complete. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * THE FOOT * * 5285 ................................................ * * Plantar fasciitis. * * MUSCLE INJURIES * * * * Miscellaneous * * 5330 ................................................ 5331 ................................................ * * Rhabdomyolysis, residuals of. Compartment syndrome. * * 6. Amend Appendix C to Part 4 as follows: ■ a. Revise the entries for Amputation, Arthritis, New growths, Myositis ossificans, Tenosynovitis, Prosthetic Implants, and Hip; ■ b. Add entries in alphabetical order for Spine, Traumatic paralysis, complete; Plantar fasciitis; Rhabdomyolysis; and Compartment syndrome; and ■ c. Remove entries for Hydroarthrosis, intermittent; Synovitis; and Periostitis. ■ The revisions read as follows: Appendix C to Part 4—Alphabetical Index of Disabilities mstockstill on DSK30JT082PROD with PROPOSALS Diagnostic Code No. * * * * * * Amputation: Arm: Complete amputation, upper extremity ................................................................................................................................. Above insertion of deltoid ...................................................................................................................................................... Below insertion of deltoid ...................................................................................................................................................... Digits, five of one hand ................................................................................................................................................................ Digits, four of one hand: Thumb, index, long and ring ................................................................................................................................................. Thumb, index, long and little ................................................................................................................................................. Thumb, index, ring and little .................................................................................................................................................. Thumb, long, ring and little ................................................................................................................................................... Index, long, ring and little ...................................................................................................................................................... Digits, three of one hand: Thumb, index and long ......................................................................................................................................................... Thumb, index and ring .......................................................................................................................................................... Thumb, index and little .......................................................................................................................................................... Thumb, long and ring ............................................................................................................................................................ Thumb, long and little ............................................................................................................................................................ Thumb, ring and little ............................................................................................................................................................ VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 PO 00000 Frm 00043 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 * 5120 5121 5122 5126 5127 5128 5129 5130 5131 5132 5133 5134 5135 5136 5137 35732 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules Diagnostic Code No. Index, long and ring .............................................................................................................................................................. Index, long and little .............................................................................................................................................................. Index, ring and little ............................................................................................................................................................... Long, ring and little ................................................................................................................................................................ Digits, two of one hand: Thumb and index .................................................................................................................................................................. Thumb and long .................................................................................................................................................................... Thumb and ring ..................................................................................................................................................................... Thumb and little ..................................................................................................................................................................... Index and long ....................................................................................................................................................................... Index and ring ....................................................................................................................................................................... Index and little ....................................................................................................................................................................... Long and ring ........................................................................................................................................................................ Long and little ........................................................................................................................................................................ Ring and little ........................................................................................................................................................................ Single finger: Thumb ................................................................................................................................................................................... Index finger ............................................................................................................................................................................ Long finger ............................................................................................................................................................................ Ring finger ............................................................................................................................................................................. Little finger ............................................................................................................................................................................. Forearm: Above insertion of pronator teres .......................................................................................................................................... Below insertion of pronator teres .......................................................................................................................................... Leg: With defective stump ............................................................................................................................................................. Not improvable by prosthesis controlled by natural knee action .......................................................................................... At lower level, permitting prosthesis ..................................................................................................................................... Forefoot, proximal to metatarsal bones ................................................................................................................................ Toes, all, amputation of, without metatarsal loss or transmetatarsal, amputation of, with up to half of metatarsal loss .... Toe, great .............................................................................................................................................................................. Toe, other than great, with removal metatarsal head ........................................................................................................... Toes, three or more, without metatarsal involvement ........................................................................................................... Thigh: Complete amputation, lower extremity .................................................................................................................................. Upper third ............................................................................................................................................................................. Middle or lower thirds ............................................................................................................................................................ * * * * * * 5138 5139 5140 5141 5142 5143 5144 5145 5146 5147 5148 5149 5150 5151 5152 5153 5154 5155 5156 5123 5124 5163 5164 5165 5166 5170 5171 5172 5173 5160 5161 5162 * Arthritis: Degenerative, other than post-traumatic ............................................................................................................................... Gonorrheal ............................................................................................................................................................................. Other specified forms (excluding gout) ................................................................................................................................. Pneumococcic ....................................................................................................................................................................... Post-traumatic ....................................................................................................................................................................... Multi-joint (except post-traumatic and gout) .......................................................................................................................... Streptococcic ......................................................................................................................................................................... Syphilitic ................................................................................................................................................................................ Typhoid .................................................................................................................................................................................. Arthropathy .......................................................................................................................................................................................... 5003 5004 5009 5005 5010 5002 5008 5007 5006 5009 * * * * * * * Colitis, ulcerative .................................................................................................................................................................................. Compartment syndrome ...................................................................................................................................................................... mstockstill on DSK30JT082PROD with PROPOSALS * * * * * * Bones: Neoplasm, benign ......................................................................................................................................................................... Neoplasm, malignant, primary or secondary ................................................................................................................................ Shortening of the lower extremity ................................................................................................................................................ * * * * * * * Dacryocystitis ....................................................................................................................................................................................... Decompression illness ......................................................................................................................................................................... * * * * * * * Hernia: Femoral ......................................................................................................................................................................................... Hiatal ............................................................................................................................................................................................. Inguinal ......................................................................................................................................................................................... Muscle .......................................................................................................................................................................................... Ventral .......................................................................................................................................................................................... Heterotopic ossification ........................................................................................................................................................................ * VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 PO 00000 Frm 00044 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 5015 5012 5275 7323 5331 6031 5011 7340 7346 7338 5326 7339 5023 35733 Federal Register / Vol. 82, No. 146 / Tuesday, August 1, 2017 / Proposed Rules Diagnostic Code No. Hip: Flail joint ....................................................................................................................................................................................... 5254 * * * * * * Hodgkin’s disease ................................................................................................................................................................................ Hydronephrosis .................................................................................................................................................................................... * * * * * * * Myocardial infarction ............................................................................................................................................................................ Myositis ................................................................................................................................................................................................ * * * * * * * Osteomalacia, residuals of .................................................................................................................................................................. * * * * * * * Osteoporosis, residuals of ................................................................................................................................................................... * * * * * * * Paralysis: Accommodation ............................................................................................................................................................................ Agitans .......................................................................................................................................................................................... Complete, traumatic ..................................................................................................................................................................... * * * * * * * Pericarditis ........................................................................................................................................................................................... Peripheral vestibular disorders ............................................................................................................................................................ * * * * * * * Plague .................................................................................................................................................................................................. Plantar fasciitis ..................................................................................................................................................................................... * * * * * * * Prosthetic implants: Ankle replacement ........................................................................................................................................................................ Elbow replacement ....................................................................................................................................................................... Hip, resurfacing or replacement ................................................................................................................................................... Knee, resurfacing or replacement ................................................................................................................................................ * * * * * * * Retinitis ................................................................................................................................................................................................ Rhabdomyolysis, residuals of .............................................................................................................................................................. * * * * * * * Spinal stenosis ..................................................................................................................................................................................... Spine: Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome ....................................................... * * * * * * * Syndromes: Chronic Fatigue Syndrome (CFS) ................................................................................................................................................ Cushing’s ...................................................................................................................................................................................... Meniere’s ...................................................................................................................................................................................... Raynaud’s ..................................................................................................................................................................................... Sleep Apnea ................................................................................................................................................................................. Syphilis ................................................................................................................................................................................................. * * * * * * * Tenosynovitis, tendinitis, tendinosis or tendinopathy .......................................................................................................................... * mstockstill on DSK30JT082PROD with PROPOSALS * * * * * * [FR Doc. 2017–15766 Filed 7–31–17; 8:45 am] BILLING CODE 8320–01–P VerDate Sep<11>2014 17:34 Jul 31, 2017 Jkt 241001 PO 00000 Frm 00045 Fmt 4702 Sfmt 9990 E:\FR\FM\01AUP1.SGM 01AUP1 7709 7509 7006 5021 5014 5013 6030 8004 5244 7002 6204 6307 5285 5056 5052 5054 5055 6006 5330 5238 5242 6354 7907 6205 7117 6847 6310 5024 *

Agencies

DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 82, Number 146 (Tuesday, August 1, 2017)]
[Proposed Rules]
[Pages 35719-35733]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-15766]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP88

Schedule for Rating Disabilities; Musculoskeletal System and
Muscle Injuries

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

-----------------------------------------------------------------------

SUMMARY: The Department of Veterans Affairs (VA) proposes to revise the
regulations that involve the Musculoskeletal System within the VA
Schedule for Rating Disabilities (``VASRD'' or ``Rating Schedule''). VA
proposes to rename certain diagnostic codes, revise rating criteria,
give new rating guidance, add new codes, and remove obsolete codes.
These revisions would incorporate medical terminology more recent than
the last comprehensive review, as well as simplify the rating process.

DATES: Comments must be received by VA on or before October 2, 2017.

ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to Director, Regulations
Management (00REG), Department of Veterans Affairs, 810 Vermont Ave.
NW., Room 1068, Washington, DC 20420; or by fax to (202) 273-9026.
(This is not a toll-free number.) Comments should indicate that they
are submitted in response to ``RIN 2900-AP88--Schedule for Rating
Disabilities; Musculoskeletal System and Muscle Injuries.'' Copies of
comments received will be available for public inspection in the Office
of Regulation Policy and Management, Room 1063B, between the hours of
8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays).
Please call (202) 461-4902 for an appointment. (This is not a toll-free
number.) In addition, during the comment period, comments may be viewed
online through the Federal Docket Management System (FDMS) at
www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Regulations Staff
(211C), Compensation Service, Veterans Benefits Administration,
Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC
20420, (202) 461-9700. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: The National Defense Authorization Act of
2004, secs. 1501-07, Public Law 108-136, 117 Stat. 1392, established
the Veterans' Disability Benefits Commission (the ``Commission'').
Section 1502 of Public Law 108-136 mandated the Commission to study
ways to improve the disability compensation system for military
veterans. The Commission consulted with the Institute of Medicine (IOM)
to review the medical aspects of current compensation policies. In
2007, the IOM released its report titled ``A 21st Century System for
Evaluating Veterans for Disability Benefits.'' (Michael McGeary et al.
eds.2007).
The IOM report was notable in several respects. The IOM observed
that, in part, the Rating Schedule was inadequate in areas because it
contained obsolete information and did not

[[Page 35720]]

sufficiently integrate current and accepted diagnostic procedures. In
addition, the IOM observed that the current body system organization of
the Rating Schedule does not reflect current knowledge of the
relationships between conditions and comorbidities.
Following the release of the IOM report, VA created a
musculoskeletal system workgroup. The goals adopted by the workgroup
were to: (1) Improve and update the process that VA uses to assign
levels of disability after it grants service connection; (2) improve
the fairness in adjudicating disability benefits for service-connected
veterans; and (3) invite public participation. The workgroup was co-
chaired by the Veterans Health Administration and Veterans Benefits
Administration. The workgroup was comprised of subject matter experts
from VA, the Department of Defense, and medical academia. The workgroup
held a public forum in Washington, DC, during August 2010, where it
discussed current regulations and possible revisions. The workgroup
held a second public forum in Washington, DC, during June 2012, where
it shared a draft proposal for comment.
The workgroup met periodically during and after the public forums
to continue its revision efforts. The regulation-drafting phase, which
began in April 2012, continues through the publication of this proposed
rule. With this rulemaking, VA proposes to remove obsolete diagnostic
codes, modernize the names of selected diagnostic codes, revise
descriptions and criteria, and add new diagnostic codes.

The Focus of This Revision

Consistent with the IOM's recommendations, the proposed amendments
rename conditions to reflect current medicine, remove obsolete
conditions, clarify ambiguities in existing rating criteria, and add
conditions that previously did not have diagnostic codes. However, VA
experienced greater difficulty revising existing rating criteria in
many areas. After significant time and research, since an earnings loss
study had not been conducted in time to be considered during the
workgroup and rule-drafting phases, VA concluded there was only a
narrow set of circumstances where the medical literature clearly
supported the proposed changes in the absence of earnings loss
information.
As such, VA modified the approach recommended by the IOM for this
body system. Only peer-reviewed articles where at least one measureable
proxy for reduced earnings capacity was studied were deemed acceptable
to justify a reduction in the level or duration of ratings for specific
conditions (e.g., time to return to work, activity limitations related
to work, and/or participation restriction(s) from work-related tasks).
Therefore, at this time, VA proposes changes to only two codes
(diagnostic codes 5054 and 5055) where the criteria changes would
result in such a reduction.

I. Proposed Changes to Sec. 4.71a

A. Nomenclature Changes to Existing Diagnostic Codes: 5003, 5012-15,
5023, 5024 and 5242

In its review of the musculoskeletal body system, VA identified a
number of diagnostic codes (DCs) with terms that are outdated or
unclear. As such, it proposes to retitle these DCs to reflect current
medical practice and nomenclature. There are no proposed substantive
changes to the rating criteria for these eight DCs.
VA proposes to retitle DC 5003, currently ``Arthritis, degenerative
(hypertrophic or osteoarthritis)'' as ``Degenerative arthritis, other
than post-traumatic.'' No other language or criteria changes are
proposed for this diagnostic code.
Current DCs 5012 and 5015 refer to ``Bones, new growths of,
malignant'' and ``Bones, new growths of, benign,'' respectively. VA
proposes to replace the term ``new growths of'' in these DCs with the
current medical term, ``neoplasm.'' See S. Terry Canale and James H.
Beaty, Campbell's Operative Orthopedics 859-86 (benign) and 909-45
(malignant) (12th ed. 2013). DC 5012 would be titled ``Bones, neoplasm,
malignant, primary or secondary'' to indicate that both primary and
secondary neoplasms are rated under this DC to ensure consistent and
accurate evaluation. Non-substantive revisions to the language in the
note under DC 5012 are also proposed; specifically, VA proposes to add
the term ``prescribed'' to the phrase ``therapeutic procedure'' to
ensure that readers understand VA will only consider medically-directed
therapy when rating DC 5012.
VA proposes to rename DC 5013, which refers to ``Osteoporosis, with
joint manifestations,'' as ``Osteoporosis, residuals of.'' VA proposes
a similar revision to current DC 5014 by renaming ``Osteomalacia'' as
``Osteomalacia, residuals of.'' Both osteoporosis and osteomalacia, in
and of themselves, do not have any disabling characteristics. See
Kelley's Textbook of Rheumatology 1730-1750 (Gary S. Firestein and
Ralph C. Budd et al. eds.,10th ed. 2017). Rather, it is the residuals
of these conditions that VA evaluates. Thus, adding the reference
``residuals of'' provides more accurate instruction and information to
rating personnel.
Current DC 5023 refers to ``Myositis ossificans.'' VA proposes to
update this DC to reflect the latest medical terminology and rename DC
5023 as ``Heterotopic ossification.'' See Essentials of Physical
Medicine and Rehabilitation: Musculoskeletal Disorders, Pain and
Rehabilitation, 691-95 (Walter R. Frontera and Julie K. Silver et al.
eds., 2d ed. 2008). Additionally, VA proposes to revise DC 5024,
currently named, ``Tenosynovitis,'' to ``Tenosynovitis, tendinitis,
tendinosis, or tendinopathy.'' These newly-added conditions are
commonly seen in the veteran population and represent similar forms of
disability. See Kelley's Textbook of Rheumatology, supra at 587-604.
This update would assist rating personnel in more quickly identifying
the appropriate DC. Non-substantive revisions to the criteria of DC
5024 are also proposed.
Finally, VA proposes to retitle DC 5242, ``Degenerative arthritis
of the spine'' as ``Degenerative arthritis, degenerative disc disease
other than intervertebral disc syndrome.'' This change gives rating
personnel clear guidance whenever they encounter a diagnostic imaging
report that references degenerative disc disease without mention of
intervertebral disc syndrome (also known as disc herniation). A non-
substantive revision to the citation accompanying DC 5242 is also
proposed.

B. Substantive Revisions to Existing Diagnostic Codes: 5002, 5009-5011,
5051-5056, 5120, 5160, 5170, 5201, 5202, 5255, 5257, 5262, and 5271

In addition to modernizing the names of certain DCs, VA also
proposes substantive (i.e., not related to nomenclature) revisions to a
number of existing DCs, to include some instances of changes in the
evaluation criteria.
1. Diagnostic Code 5002
The first substantive revision proposed for Sec. 4.71a involves DC
5002, ``Arthritis rheumatoid (atrophic) As an active process.'' VA
proposes to retitle this code as ``Multi-joint arthritis (except post-
traumatic and gout), 2 or more joints, as an active process.'' VA
proposes this change to include a greater number of systemic arthritis
processes that cause multisystem effects besides rheumatoid arthritis.
The title would employ the phrase ``multi-joint'' rather than
``polyarthritis'' because polyarthritis requires 4 or more joints to

[[Page 35721]]

be involved. VA would provide, in Note (1), a non-exhaustive list of
conditions rated under this code (rheumatoid arthritis, psoriatic
arthritis, spondyloarthropathies, etc.). See Kelley's Textbook of
Rheumatology, supra at 615-616. VA would also remove the language
currently in DC 5002 regarding chronic residuals and, in Note (2),
provide a directive to rate chronic residuals under DC 5003. VA
proposes this change because the current language used for chronic
residuals in DC 5002 is very similar to DC 5003 and its removal would
simplify the schedule. Finally, VA would redesignate the code's current
note as Note (3) and add a prohibition that prevents combining ratings
from active process with DC 5003, instead directing rating personnel to
assign the higher evaluation.
2. Diagnostic Code 5009
VA proposes that diagnostic code 5009, currently titled
``Arthritis, other types (specify),'' be retitled as ``Other specified
forms of arthropathy (excluding gout).'' VA proposes this change to
capture other disease processes that cause joint injury, but are not
necessarily captured within the rating schedule. The current language
accompanying DC 5009, concerning how to rate diagnostic codes 5004-
5009, would be redesignated as Note (2) and would be revised to give
guidance on how to rate both acute phase and chronic residuals. A new
Note (1) would provide a non-exhaustive list of conditions that should
be rated under this diagnostic code. No other changes are proposed for
this code.
3. Diagnostic Code 5010
Diagnostic code 5010 currently states: ``Arthritis, due to trauma,
substantiated by X-ray findings: Rate as arthritis, degenerative.'' VA
proposes to change the title and criteria to ``Post-traumatic
arthritis: Rate as limitation of motion, dislocation, or other
specified instability under the affected joint. If there are 2 or more
joints affected, each rating shall be combined in accordance with Sec.
4.25.'' VA proposes the title change to distinguish between joint
conditions arising from traumatic causes and joint conditions resulting
from systemic processes. This distinction is important, as the natural
history (and ultimately the severity of disability) differs between
joint conditions stemming from trauma as opposed to joint conditions
related to systemic processes.
VA proposes the change in criteria to provide a more accurate
approach to rating joint injuries resulting from trauma. The trauma
process is a different event for each affected joint, as opposed to a
condition such as rheumatoid arthritis, where the same systemic process
can affect more than one joint in the same manner. VA also proposes the
directive to combine ratings for separate joints affected by traumatic
injury in accordance with Sec. 4.25 so there will be no
misunderstanding for rating personnel when encountering this situation.
It is important to note that, as a result of these changes, DC 5010
would no longer rate joints affected by trauma-related arthritis under
the criteria of DC 5003.
4. Diagnostic Code 5011
The next proposed substantive revision to Sec. 4.71a is DC 5011,
currently named ``Bones, caisson disease of.'' VA proposes to first
revise the title of this DC to ``Decompression illness'' to ensure use
of the most modern terminology. See Richard D. Vann et al.,
``Decompression Illness,'' 377 Lancet 153-64 (2010). VA also proposes
to revise the rating criteria for DC 5011, which currently direct
rating personnel to ``Rate as arthritis, cord involvement, or deafness,
depending on the severity of disabling manifestations.'' The proposed
changes would provide more detailed instructions on how to rate
manifestations associated with decompression illness that are outside
of the musculoskeletal system (i.e., not arthritic). It is well
established among medical experts that the most common residual
manifestations from decompression illness involve the vestibule-
cochlear system (e.g., hearing impairment, dizziness, vertigo),
respiratory system (e.g., obstructive lung disease, pulmonary blebs) or
neurologic system (e.g., peripheral neuropathy, stroke, paralysis). As
such, VA proposes to direct rating personnel to consider evaluations
within the auditory system for vestibular residuals, the respiratory
system for pulmonary barotrauma residuals, and the neurologic system
for cerebrovascular accident residuals. Id.
5. Diagnostic Codes 5051-5056
Since the last revision to the musculoskeletal system schedule, the
medical community has been employing a new treatment approach, joint
resurfacing, for selected joints (particularly the hip and knee). There
are important similarities between joint resurfacing and prosthetic
joint replacement. Joint resurfacing takes about the same time to
perform and the recovery/rehabilitation periods are similar to
comparable prosthetic joint replacement. This means that the impact on
earnings capacity caused by the convalescence and rehabilitation from
joint resurfacing is comparable to prosthetic joint replacement.
However, there are significant differences with joint resurfacing,
including: (1) Joint resurfacing preserves more of the original
anatomy; and, (2) in most cases, joint resurfacing restores more of the
original joint function than the prosthetic joint replacement.
Therefore, less residual disability typically results from joint
resurfacing as compared to prosthetic joint replacement. Currently, VA
does not compensate for the disability associated with joint
resurfacing, despite the similar impact on earnings capacity as
prosthetic joint replacement.
To rectify this disparity, VA proposes to incorporate joint
resurfacing within DCs 5054 and 5055 (hip and knee replacement,
respectively), since more research assessing convalescence,
rehabilitation, and functional recovery concerns these two joints. The
DC titles would be revised to incorporate resurfacing, and the 100
percent evaluation for prosthetic hip and knee replacement would also
apply to resurfacing these two joints. However, after the 100 percent
evaluation period ends, further evaluation would assess the limitation
of motion DCs for the hip and knee, rather than the prosthetic joint
replacement of either the hip or knee, because, as previously stated,
there is less of an expectation of residual disability with joint
resurfacing. A note would be added to DCs 5054 and 5055 directing
rating personnel, at the conclusion of the 100 percent evaluation
period, to evaluate hip joint resurfacing claims under DCs 5250-5255
and knee joint resurfacing claims under DCs 5256-5262.
VA currently evaluates total joint replacements by assigning a 100
percent evaluation for 1 year following implantation of a prosthesis.
After 1 year, VA assigns a minimum evaluation, with higher evaluations
for complications or residuals such as weakness, pain, and limitation
of motion. The evaluations assigned under these DCs are intended to
encompass all musculoskeletal residuals under Sec. 4.71a. Separate
evaluations may be assigned for residuals such as scars or neurological
deficits pursuant to Sec. 4.14.
VA proposes two modifications in this regard. First, a note prior
to DCs 5051 to 5056 would clarify that separate evaluations may not be
assigned under Sec. 4.71a for the joint that was resurfaced or
replaced by a prosthesis unless otherwise directed. This note is
intended to clarify current practice and ensure consistent application
of these DCs among rating personnel.

[[Page 35722]]

In addition, for DCs 5054 and 5055, VA proposes to reduce the 100
percent evaluation period from 1 year to 4 months. Current medical
practice for these conditions has recovery timelines that in most cases
permit return to work well short of 1 year. In a review of studies
looking at factors affecting return to work, the average time for
return to work was between 1.1 and 13.9 weeks for hip arthroplasty and
between 8.0 and 12.0 weeks for knee arthroplasty. See Claire Tilbury et
al., ``Return to work after total hip and knee arthroplasty: a
systematic review,'' 53 Rheumatology 512-525 (2014).
6. Diagnostic Code 5120
VA currently evaluates amputations of the arm that involve
disarticulation under DC 5120 as 90 percent disabling regardless of
dominant arm involvement At the outset, VA proposes to revise the name
of this DC to ``Complete amputation, upper extremity,'' as this is a
more accurate description of the amputation level and site.
Second, VA proposes to create two levels of disability under DC
5120 for rating purposes. One level would be titled ``Disarticulation
(involving complete removal of the humerus only)'' and would provide a
90 percent compensation level for either major or minor extremity
involvement; this level would be consistent with the current
compensation level under DC 5120. However, the second level, to be
titled ``Forequarter amputation (involving complete removal of the
humerus along with any portion of the scapula, clavicle, and/or
ribs),'' would provide for 100 percent compensation for either dominant
or non-dominant extremity involvement. See Canale, supra at 659-71.
Although both levels represent complete amputation of the upper
extremity, VA believes a higher level of compensation is warranted for
forequarter amputation because it is a more extensive amputation than
disarticulation and results in a more significant occupational impact.
7. Diagnostic Code 5160
For reasons similar to those discussed immediately above, VA
proposes two revisions of DC 5160, which pertains to amputation of the
thigh at the level of disarticulation with loss of extrinsic pelvic
girdle muscles. First, VA proposes to retitle this DC to ``Complete
amputation, lower extremity'' to more accurately describe the
amputation level and site.
VA also proposes to create two levels of criteria for rating
purposes. One would be titled ``Disarticulation (involving complete
removal of the femur and intrinsic pelvic musculature only)'' and would
provide a 90 percent rating that is consistent with the current rating
under DC 5160. The second level, titled ``Trans-pelvic amputation
(involving complete removal of the femur and intrinsic pelvic
musculature along with any portion of the pelvic bones),'' would
provide for a 100 percent rating. See Canale, supra at 651-58. VA
believes that a higher level of compensation is warranted for trans-
pelvic amputation because it is a more extensive amputation than
disarticulation and results in a more significant occupational impact.
VA also proposes to insert a note under DC 5160 directing rating
personnel to separately evaluate residuals involving other body
systems, such as bowel or bladder impairment, under the appropriate
diagnostic code.
8. Diagnostic Code 5170
Current DC 5170 refers to ``Toes, all, amputation of, without
metatarsal loss.'' VA proposes to add the phrase ``or transmetatarsal,
amputation of, with up to half of metatarsal loss'' to include a
residual of toe amputation that causes similar disability. See Canale,
supra at 622-23. No change to the current level of compensation is
proposed.
9. Diagnostic Code 5201
VA currently assigns ratings for limitation of motion of the arm at
the shoulder where motion is limited to 25 degrees from the side, 45
degrees (midway between the side and shoulder level), or 90 degrees (at
the shoulder level).
VA proposes to clarify the terminology used in these criteria by
adding ranges of motion of the shoulder. Specifically, VA proposes to
assign a 40 percent rating for a major joint, or 30 percent for a minor
joint, where flexion and/or abduction is limited to 25 degrees from the
side. VA also proposes to assign a 30 percent rating for a major joint,
or 20 percent for a minor joint, where motion is limited to ``midway
between side and shoulder level,'' defined as flexion and/or abduction
limited to 45 degrees or less. Finally, VA proposes to assign a 20
percent rating for a major or minor joint where motion is limited ``at
shoulder level,'' defined as flexion and/or abduction limited to 90
degrees or less.
These changes are not intended to alter the rating criteria. The
proposed changes simply clarify the specific ranges of motion that
qualify as limitations to ensure rating personnel consistently apply
these criteria.
10. Diagnostic Code 5202
Currently, VA assigns a 20 percent rating for either shoulder joint
when there are infrequent episodes of dislocation of the humerus at the
scapulohumeral joint, with guarding of movement only at the shoulder
level. VA proposes to define ``the shoulder level'' as flexion and/or
abduction at 90 degrees. This change is not intended to alter the
rating criteria. The proposed change simply clarifies the specific
ranges of motion that qualify as limitations to ensure rating personnel
consistently apply these criteria.
11. Diagnostic Code 5255
VA currently evaluates malunion of the femur by assigning a 30
percent rating for a ``marked knee or hip disability,'' a 20 percent
rating for a ``moderate knee or hip disability,'' and a 10 percent
rating for a ``slight knee or hip disability.'' These criteria are
subjective and the terminology is vague, resulting in inconsistent
ratings.
Therefore, VA proposes removing this terminology and replacing it
with an instruction to rate malunion of the femur as a knee or hip
disability, whichever is predominant, under existing DCs that contain
objective criteria. Specifically, this condition may be rated under DCs
5256 (Knee, ankylosis of), 5257 (Knee, other impairment of), 5260 (Leg,
limitation of flexion of), 5261 (Leg, limitation of extension of), 5250
(Hip, ankylosis of), 5251 (Thigh, limitation of extension of), 5252
(Thigh, limitation of flexion of), 5253 (Thigh, impairment of), or 5254
(Hip, flail joint). This change would ensure that rating personnel
consistently evaluate this disability based on objective criteria.
12. Diagnostic Code 5257
VA currently assigns ratings for recurrent subluxation or lateral
instability of the knee based on whether the condition is slight (10
percent), moderate (20 percent), or severe (30 percent). These criteria
are subjective and the terminology is vague, resulting in VA assigning
inconsistent ratings.
When the condition involves patellar instability of the knee (due
to recurrent patellar subluxation or patellar dislocation), one can
determine the severity of functional impairment in large part by 1) the
presence, or absence of, anatomic abnormalities (e.g., direct damage to
patellofemoral ligament complex, ``flake'' fractures, or abnormalities
affecting the patella and/or femoral trochlea); and 2) whether
conservative treatment prevents recurrent instability. See Alexis C.

[[Page 35723]]

Colvin and Robin V. West, ``Current Concepts Review: Patellar
Instability,'' J. Bone & Joint Surgery--Am. Volume 90: 2751-62 (2008).
Instability or laxity of the knee that involves other stabilizing
structures of the knee such as the collateral ligaments (medial or
lateral) or the cruciate ligaments (anterior or posterior) are given a
``grade'' depending upon the amount of translation, in millimeters, of
the joint (e.g., a grade 1 injury of the posterior cruciate ligament
(PCL) is represented by 0 to 5 millimeters (mm) of translation). T. K.
Kakarlapudi et al., ``Knee instability: isolated and complex,'' 34 Br.
J. Sports Med. 395-400 (2000). Resulting functional impairment depends
upon the grade of the injury and whether surgical intervention is
required. Id. The higher the number grade is, the more severe the
injury; that is, grade 1 would represent the least severe injury, grade
2 would be a more severe injury, and grade 3 would be the most severe
injury.
Therefore, VA proposes replacing the current subjective terms with
the following objective criteria: a 30 percent rating would be assigned
for persistent grade 3 instability despite operative intervention and
for which ambulation requires both bracing and an assistive device
(e.g., cane(s), crutch(es), or a walker), as prescribed by a physician;
or, in the case of patellar instability, persistent instability despite
surgical repair (whether after the primary subluxation/dislocation
event or due to recurrent instability). A 20 percent would be assigned
for persistent grade 3 instability without operative intervention, but
when ambulation requires both bracing and an assistive device (e.g.,
cane(s), crutch(es), or a walker), as prescribed by a physician; or, in
the case of patellar instability, recurrent instability persists due to
one or more documented underlying anatomic abnormalities, without
surgical repair. A 10 percent evaluation would be assigned for
persistent grade 1, 2, or 3 instability which requires an ambulation
assistive device or bracing, as prescribed by a physician; or, in the
case of patellar instability, recurrent instability persists without
documented underlying anatomic abnormalities, without surgical repair.
These criteria would take into account both the grade of the injury, as
well as functional impairment resulting from the injury.
VA also proposes a note defining the grading of instability. Note
(1) would specify that grade 1 instability requires 0-5 mm of joint
translation, while grade 2 requires translation of 6-10 mm, and grade 3
requires joint translation equal to or greater than 11 mm. These levels
of instability or laxity are based upon modern medical practice. See
Campbell's Operative Orthopedics, supra at 2157.
VA proposes a second note to clarify what constitutes surgical
repair of patellar instability. Note (2) would specify that any
operative procedure which does not involve actual anatomical structural
repair would not qualify as surgical repair for the purposes of
compensation. This note is specifically designed to exclude procedures
that are not designed to repair instability or subluxation, such as
joint aspiration, arthroscopy to remove loose bodies, and so forth.
In addition, DC 5257 currently refers to ``lateral instability.''
Under current practice, any instability or laxity of the knee is
evaluated under this code. Therefore, VA proposes to remove the term
``lateral,'' so that this code also encompasses other specified forms
of instability and/or laxity.
13. Diagnostic Code 5262
VA currently rates malunion of the tibia and fibula by assigning a
30 percent rating for a ``marked knee or ankle disability,'' a 20
percent rating for a ``moderate knee or ankle disability,'' and a 10
percent rating for a ``slight knee or ankle disability.'' These
criteria are subjective and the terminology is vague. This results in
rating personnel assigning inconsistent ratings under these criteria.
Therefore, VA proposes removing this terminology and replacing it
with an instruction to rate malunion of the tibia or fibula as a knee
or ankle disability, whichever is predominant, under existing DCs that
contain objective criteria. Specifically, this condition may be
evaluated under DCs 5256 (Knee, ankylosis of), 5257 (Knee, other
impairment of), 5260 (Leg, limitation of flexion of), 5261 (Leg,
limitation of extension of), 5270 (Ankle, ankylosis of), or 5271
(Ankle, limited motion of). This change would ensure that rating
personnel consistently assign evaluations based on objective criteria.
Another condition commonly claimed for disability compensation is
medial tibial stress syndrome (MTSS), also known as ``shin splints.''
It is a benign but painful condition that is typically diagnosed simply
by history and physical examination, though imaging studies such as
plain radiographs, bone scans, or magnetic resonance imaging (MRI) can
be used in borderline cases, as well as to diagnose other conditions.
The vast majority of cases respond to conservative therapy, such as
rest, shock-absorbing insoles, and electrowave shock therapy. The rare
persistent cases that do not respond to conservative treatment can be
treated with surgical intervention. To that end, VA proposes to modify
the criteria for DC 5262 to account for MTSS as well as associated
conditions. See M. Reshef and D. Guelich, ``Medial Tibial Stress
Syndrome,'' 31 Clinical Sports Med. 273-90 (2012).
14. Diagnostic Code 5271
VA currently assigns ratings for limited motion of the ankle
depending upon whether the limitation is moderate (10 percent) or
marked (20 percent). These criteria are subjective and the terminology
is vague, resulting in inconsistent evaluations.
Therefore, VA proposes to define marked limitation of motion as
less than 5 degrees dorsiflexion or less than 10 degrees plantar
flexion. VA also proposes to define moderate limitation of motion as
less than 15 degrees dorsiflexion or less than 30 degrees plantar
flexion. As VA currently uses these standards to define marked and
moderate, this change is intended as a clarification of current policy
and would ensure consistent application of these criteria among rating
personnel.

C. Proposed New Diagnostic Codes

1. Diagnostic Code 5244
The current Rating Schedule does not provide instructions for
rating complete traumatic paralysis, i.e., paraplegia or quadriplegia;
however, this disability is not uncommon in the veteran population. As
such, VA proposes the addition of DC 5244, ``Traumatic paralysis,
complete.''
The proposed criteria for DC 5244 would direct personnel to rate
paraplegia, or functional loss of the lower limbs and trunk, under DC
5110. DC 5110 applies to loss of use of both feet and provides for a
100 percent disability rating with entitlement to special monthly
compensation. Proposed DC 5244 would also provide instructions for
rating quadriplegia, or paralysis of all four limbs (i.e., the entire
body below the neck). Specifically, VA proposes to rate quadriplegia
under both DC 5109, loss of use of both hands, and DC 5110, loss of use
of both feet, and combine. In practice, a veteran with service-
connected quadriplegia would be entitled to two 100 percent ratings,
which combine under 38 CFR 4.25 to a total evaluation of 100 percent.
The veteran would also be entitled to special monthly compensation.
2. Diagnostic Code 5285
VA currently evaluates foot injuries not specifically listed in
Sec. 4.71a under

[[Page 35724]]

DC 5284 as ``Foot injuries, other.'' Plantar fasciitis, a foot
disability seen in the veteran population, is generally rated under
this DC. However, unlike other unlisted foot injuries and conditions,
which can often result in a variety of signs and symptoms with varying
degrees of disability, plantar fasciitis, and its functional effects,
are very well defined. See Sports Medicine and Arthroscopic Surgery of
the Foot and Ankle 83-93 (Amol Saxena ed., 2013). Plantar fasciitis,
also known as ``jogger's heel,'' is generally characterized by heel
pain due to inflammation. Craig C. Young et al., ``Plantar fasciitis,''
Medscape Reference (Feb. 4, 2014), https://emedicine.medscape.com/article/86143-overview (last visited April 15, 2014). However, even at
its most severe, this condition involves an otherwise structurally
intact foot.
There are a variety of both surgical and non-surgical treatments
that may relieve the primary symptoms of plantar fasciitis.
Conservative measures are always employed first, and frequently include
icing, stretching, non-steroidal anti-inflammatory drug (NSAID)
therapy, strapping and taping, and/or over-the-counter orthotics. Id.
at https://emedicine.medscape.com/article/86143-treatment. Other
nonsurgical treatments may include injections, physical therapy, and
custom orthotics. Id. Studies have reported a resolution incidence of
up to 90 percent with nonsurgical measures. Id. In severe cases, non-
surgical measures fail and surgery is required.
Individuals who respond to treatment, whether surgical or non-
surgical, have generally no more than slight functional limitation due
to plantar fasciitis. Further, such limitation is more associated with
the treatment(s) required to check the pain (e.g., limitation of
physical activities (such as running), injections, icing, use of
NSAIDS, surgical residuals, etc.) than with the actual disability
itself. For individuals who do not respond to treatment, the resulting
limitations may vary, but are generally more pronounced for those who
have bilateral, rather than unilateral, plantar fasciitis.
Given the foregoing, VA proposes to create a new DC, namely DC
5285, ``Plantar fasciitis,'' to rate this condition. VA intends to
evaluate this disability based on a combination of extent (one foot or
both feet) and response to treatment (responsive or nonresponsive). For
individuals whose plantar fasciitis does not respond to both surgical
and non-surgical treatment, VA proposes to award 30 percent disability
rating if both feet are affected and a 20 percent disability rating if
one foot is affected. For an individual whose plantar fasciitis (either
unilateral or bilateral) is responsive to treatment (either non-
surgical or surgical), VA proposes a 10 percent disability rating.
Finally, consistent with other foot injuries and disabilities, VA
intends to include a note with DC 5285 that would instruct rating
personnel to assign a 40 percent rating in cases where there is actual
loss of use of the foot. In cases where a veteran's bilateral plantar
fasciitis has not improved following surgery and there is actual loss
of use of one foot, this would result in a 40 percent evaluation for
that foot and a 20 percent evaluation for the other foot that was not
responsive to treatment, but did not result in loss of use.

D. Removal of Existing Diagnostic Codes

VA proposes to remove three obsolete codes from Sec. 4.71a. The
first two, DC 5018 and DC 5020, refer to ``Hydrarthrosis,
intermittent'' and ``Synovitis,'' respectively. Both hydrarthrosis and
synovitis are signs found on physical examination. The disability from
a specific condition that causes either hydrarthrosis or synovitis
(e.g., rheumatoid arthritis, psoriatic arthritis, or pseudogout) is
captured within current evaluation criteria for the specific disabling
condition. See Kelley's Textbook of Rheumatology, supra at 588. Given
that VA's disability compensation system is designed to compensate for
disabilities, it is not appropriate to list either sign as its own DC.
For similar reasons, VA proposes to remove DC 5022,
``Periostitis.'' Current medical terminology refers to ``periosteal
reaction'' in order to include all of the possible causes, such as
bleeding, infection, or tumor. In contrast, ``periostitis'' refers to a
non-specific inflammatory process due to a number of diagnoses that
could potentially result in service connection. Since an evaluation
should be conducted under the primary diagnosis, rather than a
radiographic finding such as periostitis, VA intends to remove DC 5022.
See Radiologic-Pathologic Correlations from Head to Toe: Understanding
the Manifestations of Disease 668 (Nicholas C. Gourtsoyiannis and Pablo
R. Ros eds., 2005).

II. Proposed Changes to Sec. 4.73

Section 4.73 provides VA's schedule for rating muscle injuries.
Following its review of this body system, VA proposes the addition of
two DCs for conditions that previously required analogous rating.
The first proposed code, DC 5330, would apply to residuals of
rhabdomyolysis, in which muscle tissue breaks down rapidly. See Janice
L. Zimmerman and Michael C. Shen, ``Rhabdomyolysis,'' 144(3) CHEST
1058-65 (2013). Although VA proposes to rate this condition based on
residual impairment to the affected muscle group(s), it believes that a
specific DC is needed as there is no current instruction to rating
personnel as to how to evaluate this condition. Furthermore, in
addition to provide rating instructions to evaluate each affected
muscle group, VA proposes to include a note directing rating personnel
to separately evaluate any chronic renal complications that may be
associated with this condition.
The second DC VA proposes to add to Sec. 4.73 is DC 5331,
``Compartment syndrome.'' Similar to DC 5330, VA proposes to rate
compartment syndrome, a condition in which there is increased pressure
within the muscles, according to the affected muscle group(s). See
Canale, supra at 2311-21. The addition of this DC would provide clear
instructions to rating personnel; it would also eliminate the need for
analogous coding for a condition seen in the veteran population.
In addition, VA proposes to add a second note at the beginning of
Sec. 4.73 directing that rating personnel consider the objective
criteria contained in Sec. 4.56 when determining whether a muscle
disability is slight, moderate, moderately severe, or severe under DCs
5301 to 5323. Although Sec. 4.56 references these DCs, the levels of
severity are not defined in Sec. 4.73, nor does that section currently
reference Sec. 4.56. Therefore, VA proposes to add this note for a
cross-reference.

Executive Orders 12866 and 13563

Executive Orders 12866 and 13563 direct agencies to assess the
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, and other advantages; distributive impacts;
and equity). Executive Order 13563 (Improving Regulation and Regulatory
Review) emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
Executive Order 12866 (Regulatory Planning and Review) defines a
``significant regulatory action,'' which requires review by the Office
of Management and Budget (OMB), as ``any regulatory action that is
likely to result in a rule that may:

[[Page 35725]]

(1) Have an annual effect on the economy of $100 million or more or
adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment, public
health or safety, or State, local, or tribal governments or
communities; (2) Create a serious inconsistency or otherwise interfere
with an action taken or planned by another agency; (3) Materially alter
the budgetary impact of entitlements, grants, user fees, or loan
programs or the rights and obligations of recipients thereof; or (4)
Raise novel legal or policy issues arising out of legal mandates, the
President's priorities, or the principles set forth in this Executive
Order.''
VA has examined the economic, interagency, budgetary, legal, and
policy implications of this proposed rule, and it has been determined
not to be a significant regulatory action under Executive Order 12866.
VA's impact analysis can be found as a supporting document at
https://www.regulations.gov, usually within 48 hours after the
rulemaking document is published. Additionally, a copy of the
rulemaking and its impact analysis are available on VA's Web site at
https://www1.va.gov/orpm/, by following the link for ``VA Regulations
Published.''

Unfunded Mandates

The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in the expenditure by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any one year. This proposed rule would have no such
effect on State, local, and tribal governments, or on the private
sector.

Paperwork Reduction Act

Although this document contains provisions constituting a
collection of information under the provisions of the Paperwork
Reduction Act (44 U.S.C. 3501 et seq.), no new or proposed revised
collections of information are associated with this proposed rule. The
information collection requirements are currently approved by the
Office of Management and Budget (OMB) and have been assigned OMB
control numbers 2900-0747, 2900-0776, 2900-0778, and 2900-0802 through
2900-0813. While no modifications to these forms are made by this
rulemaking, the total incremental cost to all respondents is estimated
to be $198,002.21 during the first year. See Regulatory Impact Analysis
for a full explanation.

Regulatory Flexibility Act

The Secretary hereby certifies that this proposed rule would not
have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act, 5
U.S.C. 601-612. This proposed rule would not affect any small entities.
Only VA beneficiaries could be directly affected. Therefore, pursuant
to 5 U.S.C. 605(b), this proposed rule would be exempt from the initial
and final regulatory flexibility analysis requirements of sections 603
and 604.

Catalog of Federal Domestic Assistance Numbers and Titles

The Catalog of Federal Domestic Assistance program numbers and
titles for this rule are 64.013, Veterans Prosthetic Appliances;
64.109, Veterans Compensation for Service-Connected Disability; and
64.110, Veterans Dependency and Indemnity Compensation for Service-
Connected Death.

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this
document and authorized the undersigned to sign and submit the document
to the Office of the Federal Register for publication electronically as
an official document of the Department of Veterans Affairs. Gina S.
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs,
approved this document on June 20, 2017, for publication.

Dated: July 21, 2017.
Michael Shores,
Director, Regulation Policy & Management, Office of the Secretary,
Department of Veterans Affairs.

List of Subjects in 38 CFR Part 4

Disability benefits, Pensions, Veterans.

For the reasons set out in the preamble, VA proposes to amend 38
CFR part 4 as follows:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

0
1. The authority citation for part 4, subpart B continues to read as
follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

0
2. Amend Sec. 4.71a as follows:
0
a. Revise diagnostic codes 5002, 5003, 5009-5015, 5023-5024, 5054,
5055, 5120, 5160, 5170, 5201, 5202, 5242, 5255, 5257, 5262, and 5271.
0
b. Remove diagnostic codes 5018, 5020, and 5022.
0
c. Add new introduction note to diagnostic codes 5051 through 5056 and
add new diagnostic codes 5244 and 5285.
The revisions and additions read as follows:

Sec. 4.71a Schedule of ratings--musculoskeletal system.

Acute, Subacute, or Chronic Diseases
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------

* * * * * * *
5002 Multi-joint arthritis (except post-traumatic and
gout), 2 or more joints, as an active process:

* * * * * * *
One or two exacerbations a year in a well- 20
established diagnosis..............................
Note (1): Examples of conditions rated using this
diagnostic code include, but are not limited to,
rheumatoid arthritis, psoriatic arthritis, and
spondyloarthropathies.
Note (2): For chronic residuals, rate under
diagnostic code 5003.
Note (3): The ratings for the active process will
not be combined with the residual ratings for
limitation of motion, ankylosis, or diagnostic code
5003. Instead, assign the higher evaluation.
5003 Degenerative arthritis, other than post-traumatic:

* * * * * * *
5009 Other specified forms of arthropathy (excluding
gout).

[[Page 35726]]

Note (1): Other specified forms of arthropathy
include, but are not limited to, Charcot
neuropathic, hypertrophic, crystalline, and other
autoimmune arthropathies.
Note (2): With the types of arthritis, diagnostic
codes 5004 through 5009, rate the acute phase under
diagnostic code 5002; rate any chronic residuals
under diagnostic code 5003.
5010 Post-traumatic arthritis: Rate as limitation of
motion, dislocation, or other specified instability
under the affected joint. If there are 2 or more joints
affected, each rating shall be combined in accordance
with Sec. 4.25.
5011 Decompression illness: Rate manifestations under
the appropriate diagnostic code within the affected
body system, such as arthritis for musculoskeletal
residuals; auditory system for vestibular residuals;
respiratory system for pulmonary barotrauma residuals;
and neurologic system for cerebrovascular accident
residuals.
5012 Bones, neoplasm, malignant, primary or secondary... 100
Note: The 100 percent rating will be continued for 1
year following the cessation of surgical, X-ray,
antineoplastic chemotherapy or other prescribed
therapeutic procedure. If there has been no local
recurrence or metastases, rate based on residuals.
5013 Osteoporosis, residuals of.
5014 Osteomalacia, residuals of.
5015 Bones, neoplasm, benign.

* * * * * * *
5023 Heterotopic ossification.
5024 Tenosynovitis, tendinitis, tendinosis or
tendinopathy.
Evaluate the diseases under diagnostic codes 5013
through 5024 as degenerative arthritis, based on
limitation of motion of affected parts. However,
evaluate gout under diagnostic code 5003.

* * * * * * *
------------------------------------------------------------------------

Prosthetic Implants and Resurfacing
------------------------------------------------------------------------
Rating
-------------------------------
Major Minor
------------------------------------------------------------------------
Note: When an evaluation is assigned for joint resurfacing or the
prosthetic replacement of a joint under diagnostic codes 5051-5056, an
additional rating under Sec. 4.71a may not also be assigned for that
joint, unless otherwise directed.
------------------------------------------------------------------------

* * * * * * *
5054 Hip, resurfacing or replacement
(prosthesis)
Prosthetic replacement of the head of
the femur or of the acetabulum:
For 4 months following implantation .............. 100
of prosthesis or resurfacing.......
Note: At the conclusion of the 100
percent evaluation period, evaluate
resurfacing under diagnostic codes
5250 through 5255.

* * * * * * *
5055 Knee, resurfacing or replacement
(prosthesis)
Prosthetic replacement of knee joint:
For 4 months following implantation .............. 100
of prosthesis or resurfacing.......
Note: At the conclusion of the 100
percent evaluation period, evaluate
resurfacing under diagnostic codes
5256 through 5262.

* * * * * * *
------------------------------------------------------------------------

Amputations: Upper Extremity
------------------------------------------------------------------------
Rating
-------------------------------
Major Minor
------------------------------------------------------------------------
Arm, amputation of:
5120 Complete amputation, upper
extremity:
Forequarter amputation 100 100
(involving complete removal of
the humerus along with any
portion of the scapula,
clavicle, and/or ribs).........
Disarticulation (involving 90 90
complete removal of the humerus
only)..........................

* * * * * * *
------------------------------------------------------------------------

Amputations: Lower Extremity
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Thigh, amputation of:

[[Page 35727]]

5160 Complete amputation, lower extremity
Trans-pelvic amputation (involving complete 100
removal of the femur and intrinsic pelvic
musculature along with any portion of the
pelvic bones)..................................
Disarticulation (involving complete removal of 90
the femur and intrinsic pelvic musculature
only)..........................................
Note: Separately evaluate residuals involving
other body systems (e.g., bowel impairment,
bladder impairment) under the appropriate
diagnostic code.

* * * * * * *
5170 Toes, all, amputation of, without metatarsal 30
loss or transmetatarsal, amputation of, with up to
half of metatarsal loss............................

* * * * * * *
------------------------------------------------------------------------

The Shoulder and Arm
------------------------------------------------------------------------
Rating
-------------------------------
Major Minor
------------------------------------------------------------------------

* * * * * * *
5201 Arm, limitation of motion of:
Flexion and/or abduction limited to 40 30
25[deg] from side..................
Midway between side and shoulder 30 20
level (flexion and/or abduction
limited to 45[deg])................
At shoulder level (flexion and/or 20 20
abduction limited to 90[deg])......
5202 Humerus, other impairment of:
Loss of head of (flail shoulder).... 80 70
Nonunion of (false flail joint)..... 60 50
Fibrous union of.................... 50 40
Recurrent dislocation of at .............. ..............
scapulohumeral joint:
With frequent episodes and guarding 30 20
of all arm movements...............
With infrequent episodes, and 20 20
guarding of movement only at
shoulder level (flexion and/or
abduction at 90[deg])..............
Malunion of:
Marked deformity.................... 30 20
Moderate deformity.................. 20 20

* * * * * * *
------------------------------------------------------------------------

The Spine
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
General Rating Formula for Diseases and Injuries of the
Spine

* * * * * * *
5242 Degenerative arthritis, degenerative disc disease
other than intervertebral disc syndrome (also, see
diagnostic code 5003)..................................

* * * * * * *
5244 Traumatic paralysis, complete:
Paraplegia: Rate under diagnostic code 5110.
Quadriplegia: Rate separately under diagnostic codes
5109 and 5110 and combine evaluations in accordance
with Sec. 4.25.
------------------------------------------------------------------------
The Hip and Thigh
------------------------------------------------------------------------

* * * * * * *
5255 Femur, impairment of:
Fracture of shaft or anatomical neck of:
With nonunion, with loose motion (spiral or 80
oblique fracture)..............................
With nonunion, without loose motion, weight 60
bearing preserved with aid of brace............
Fracture of surgical neck of, with false joint.. 60
Malunion of:
Evaluate under diagnostic codes 5256, 5257,
5260, or 5261 for the knee, or 5250-5254 for
the hip, whichever results in the highest
evaluation.
------------------------------------------------------------------------
The Knee and Leg
------------------------------------------------------------------------

* * * * * * *
5257 Knee, other impairment of:

[[Page 35728]]

Recurrent subluxation or instability:
Persistent grade 3 instability despite operative 30
intervention and a physician prescribes both
bracing and assistive device (e.g., cane(s),
crutch(es), or a walker) for ambulation........
Persistent grade 3 instability without operative 20
intervention, and a physician prescribes both
bracing and assistive device (e.g., cane(s),
crutch(es), or a walker) for ambulation........
Persistent grade 1, 2, or 3 instability and a 10
physician prescribes an assistive device (e.g.,
cane(s), crutch(es), or a walker) or bracing
for ambulation.................................
Patellar instability:
With documented surgical repair, persistent 30
instability either after the primary
subluxation/dislocation event or due to
recurrent instability..........................
Without surgical repair, recurrent instability 20
with one or more documented underlying anatomic
abnormalities (e.g., direct damage to
patellofemoral ligament complex, ``flake''
fractures, or abnormalities affecting the
patella and/or femoral trochlea)...............
Without surgical repair, recurrent instability 10
without documented underlying anatomic
abnormalities..................................
Note (1): Grade 1 is defined as 0-5 mm of joint
translation, grade 2 is defined as 6-10 mm of joint
translation, and grade 3 is defined as joint
translation of equal to or greater than 11 mm.
Note (2): For patellar instability, a surgical
procedure that does not involve repair of one or
more anatomic structures that contribute to the
underlying instability shall not qualify as
surgical repair for compensation purposes
(including, but not limited to, arthroscopy to
remove loose bodies and joint aspiration).

* * * * * * *
5262 Tibia and fibula, impairment of:
Nonunion of, with loose motion, requiring brace..... 40
Malunion of:
Evaluate under diagnostic codes 5256, 5257,
5260, or 5261 for the knee, or 5270 or 5271 for
the ankle, whichever results in the highest
evaluation.
Medial tibial stress syndrome (MTSS), or shin
splints:
With imaging evidence (X-rays, bone scan, or 30
MRI), requiring treatment for no less than 12
consecutive months and unresponsive to shoe
orthotics, other conservative treatment, or
surgery, both lower extremities................
With imaging evidence (X-rays, bone scan, or 20
MRI), requiring treatment for no less than 12
consecutive months, and unresponsive to shoe
orthotics, other conservative treatment, or
surgery, one lower extremity...................
With imaging evidence (X-rays, bone scan, or 10
MRI), requiring treatment for no less than 12
consecutive months, and unresponsive to both
shoe orthotics and other conservative
treatment, one or both lower extremities.......
Treatment less than 12 consecutive months, one 0
or both lower extremities......................

* * * * * * *
------------------------------------------------------------------------
The Ankle
------------------------------------------------------------------------

* * * * * * *
5271 Ankle, limited motion of:
Marked (less than 5 degrees dorsiflexion or less 20
than 10 degrees plantar flexion)...................
Moderate (less than 15 degrees dorsiflexion or less 10
than 30 degrees plantar flexion)...................

* * * * * * *
------------------------------------------------------------------------
The Foot
------------------------------------------------------------------------

* * * * * * *
5285 Plantar fasciitis:
With symptoms not relieved by both non-surgical and
surgical treatment:
bilateral....................................... 30
unilateral...................................... 20
With symptoms relieved by either non-surgical or 10
surgical treatment, unilateral or bilateral........
Note: With actual loss of use of the foot, rate 40
percent.
------------------------------------------------------------------------
The Skull
------------------------------------------------------------------------

* * * * * * *
------------------------------------------------------------------------

(Authority: 38 U.S.C. 1155)
* * * * *
0
3. In Sec. 4.73, add new introduction notes (1) and (2) and add new
diagnostic codes 5330 and 5331 to read as follows:

Sec. 4.73 Schedule of ratings--muscle injuries.

Note (1): When evaluating any claim involving muscle injuries
resulting in loss of use of any extremity or loss of use of both
buttocks (diagnostic code 5317, Muscle Group XVII), refer to Sec.
3.350 of this chapter to determine whether the veteran may be
entitled to special monthly compensation.

Note (2): Ratings of slight, moderate, moderately severe, or
severe for diagnostic

[[Page 35729]]

codes 5301 through 5323 will be determined based upon the criteria
contained in Sec. 4.56.

* * * * *

Miscellaneous
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------

* * * * * * *
5330 Rhabdomyolysis, residuals of.
Rate each affected muscle group separately and
combine in accordance with Sec. 4.25.
Note: Separately evaluate any chronic renal
complications within the appropriate body system.
5331 Compartment syndrome.
Rate each affected muscle group separately and
combine in accordance with Sec. 4.25.
------------------------------------------------------------------------

(Authority: 38 U.S.C. 1155)

0
4. Amend Appendix A to Part 4 as follows:
0
a. In Sec. 4.71a, revise diagnostic codes 5002, 5003, 5012, 5024,
5051-5056, 5255, 5257;
0
b. In Sec. 4.71a, add diagnostic codes 5009-5011, 5013-5015, 5018,
5020, 5022-5023, 5120, 5160, 5170, 5201, 5202, 5242, 5244, 5262, 5271
and 5285;
0
c. In Sec. 4.73, add new introduction note and diagnostic codes 5330
and 5331.
The revisions read as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946

------------------------------------------------------------------------
Diagnostic Code
Sec. No.
------------------------------------------------------------------------
4.71a

* * * * * * *
5002 Evaluation March 1,
1963; title,
criteria, note
[insert effective
date of final rule]
5003 Added July 6, 1950;
title [insert
effective date of
final rule]

* * * * * * *
5009 Title, evaluation,
note [insert
effective date of
final rule].
5010 Title, criteria
[insert effective
date of final rule].
5011 Title, criteria
[insert effective
date of final rule].
5012 Criterion March 10,
1976; title, note
[insert effective
date of final rule].
5013 Title [insert
effective date of
final rule].
5014 Title [insert
effective date of
final rule].
5015 Title [insert
effective date of
final rule].
5018 Removed [insert
effective date of
final rule].
5020 Removed [insert
effective date of
final rule].
5022 Removed [insert
effective date of
final rule].
5023 Title [insert
effective date of
final rule].
5024 Criterion March 1,
1963; title, criteria
[insert effective
date of final rule].

* * * * * * *
5051 Added September 22,
1978; note [insert
effective date of
final rule].
5052 Added September 22,
1978; note [insert
effective date of
final rule].
5053 Added September 22,
1978; note [insert
effective date of
final rule].
5054 Added September 22,
1978; title,
criterion, and note
[insert effective
date of final rule].
5055 Added September 22,
1978; title,
criterion, and note
[insert effective
date of final rule].
5056 Added September 22,
1978; note [insert
effective date of
final rule].

* * * * * * *
5120 Title, criterion
[insert effective
date of final rule].
5160 Title, criterion, note
[insert effective
date of final rule].

* * * * * * *
5170 Title [insert
effective date of
final rule].

* * * * * * *
5201 Criterion [insert
effective date of
final rule].
5202 Criterion [insert
effective date of
final rule].

* * * * * * *
5242 Title [insert
effective date of
final rule]

* * * * * * *
5244 Added [insert
effective date of
final rule].

[[Page 35730]]

* * * * * * *
5255 Criterion July 6,
1950; criterion
[insert effective
date of final rule].

* * * * * * *
5257 Evaluation July 6,
1950; criterion and
note [insert
effective date of
final rule].

* * * * * * *
5262 Criterion [insert
effective date of
final rule].

* * * * * * *
5271 Criterion [insert
effective date of
final rule].

* * * * * * *
5285 Added [insert
effective date of
final rule].

* * * * * * *
4.73........................... ............... Introduction NOTE
criterion July 3,
1997; second NOTE
added [insert
effective date of
final rule].

* * * * * * *
5330 Added [insert
effective date of
final rule].
5331 Added [insert
effective date of
final rule].
------------------------------------------------------------------------

0
5. Amend Appendix B to Part 4 as follows:
0
a. Revise diagnostic codes 5002, 5003, 5009-5015, 5023, 5024, 5054,
5055, 5120, 5160, 5170 and 5242;
0
b. Add diagnostic codes 5244, 5285, 5330, and 5331; and
0
c. Remove diagnostic codes 5018, 5020 and 5022.
The revisions read as follows:

Appendix B to Part 4--Numerical Index of Disabilities

------------------------------------------------------------------------
Diagnostic Code No.
------------------------------------------------------------------------
THE MUSCULOSKELETAL SYSTEM
Acute, Subacute, or Chronic Diseases
------------------------------------------------------------------------

* * * * * * *
5002.............................. Multi-joint arthritis (except post-
traumatic and gout), 2 or more
joints, as an active process.
5003.............................. Degenerative arthritis, other than
post-traumatic.

* * * * * * *
5009.............................. Other specified forms of arthropathy
(excluding gout).
5010.............................. Post-traumatic arthritis.
5011.............................. Decompression illness.
5012.............................. Bones, neoplasm, malignant, primary
or secondary.
5013.............................. Osteoporosis, residuals of.
5014.............................. Osteomalacia, residuals of.
5015.............................. Bones, neoplasm, benign.

* * * * * * *
5023.............................. Heterotopic ossification.
5024.............................. Tenosynovitis, tendinitis,
tendinosis or tendinopathy.

* * * * * * *
5054.............................. Hip, resurfacing or replacement
(prosthesis).
5055.............................. Knee, resurfacing or replacement
(prosthesis).

* * * * * * *
------------------------------------------------------------------------
AMPUTATIONS: UPPER EXTREMITY
------------------------------------------------------------------------
Arm, amputation of:
5120.......................... Complete amputation, upper
extremity.

* * * * * * *
------------------------------------------------------------------------
AMPUTATIONS: LOWER EXTREMITY
------------------------------------------------------------------------
Thigh, amputation of:
5160.......................... Complete amputation, lower
extremity.

[[Page 35731]]

* * * * * * *
5170.......................... Toes, all, amputation of, without
metatarsal loss or transmetatarsal,
amputation of, with up to half of
metatarsal loss.

* * * * * * *
------------------------------------------------------------------------
SPINE
------------------------------------------------------------------------

* * * * * * *
5242.............................. Degenerative arthritis, degenerative
disc disease other than
intervertebral disc syndrome (also,
see either 5003 or 5010).

* * * * * * *
5244.............................. Traumatic paralysis, complete.

* * * * * * *
------------------------------------------------------------------------
THE FOOT
------------------------------------------------------------------------

* * * * * * *
5285.............................. Plantar fasciitis.

* * * * * * *
------------------------------------------------------------------------
MUSCLE INJURIES
------------------------------------------------------------------------

* * * * * * *
------------------------------------------------------------------------
Miscellaneous
------------------------------------------------------------------------

* * * * * * *
5330.............................. Rhabdomyolysis, residuals of.
5331.............................. Compartment syndrome.

* * * * * * *
------------------------------------------------------------------------

0
6. Amend Appendix C to Part 4 as follows:
0
a. Revise the entries for Amputation, Arthritis, New growths, Myositis
ossificans, Tenosynovitis, Prosthetic Implants, and Hip;
0
b. Add entries in alphabetical order for Spine, Traumatic paralysis,
complete; Plantar fasciitis; Rhabdomyolysis; and Compartment syndrome;
and
0
c. Remove entries for Hydroarthrosis, intermittent; Synovitis; and
Periostitis.
The revisions read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
Diagnostic
Code No.
------------------------------------------------------------------------

* * * * * * *
Amputation:
Arm:
Complete amputation, upper extremity............ 5120
Above insertion of deltoid...................... 5121
Below insertion of deltoid...................... 5122
Digits, five of one hand............................ 5126
Digits, four of one hand:
Thumb, index, long and ring..................... 5127
Thumb, index, long and little................... 5128
Thumb, index, ring and little................... 5129
Thumb, long, ring and little.................... 5130
Index, long, ring and little.................... 5131
Digits, three of one hand:
Thumb, index and long........................... 5132
Thumb, index and ring........................... 5133
Thumb, index and little......................... 5134
Thumb, long and ring............................ 5135
Thumb, long and little.......................... 5136
Thumb, ring and little.......................... 5137

[[Page 35732]]

Index, long and ring............................ 5138
Index, long and little.......................... 5139
Index, ring and little.......................... 5140
Long, ring and little........................... 5141
Digits, two of one hand:
Thumb and index................................. 5142
Thumb and long.................................. 5143
Thumb and ring.................................. 5144
Thumb and little................................ 5145
Index and long.................................. 5146
Index and ring.................................. 5147
Index and little................................ 5148
Long and ring................................... 5149
Long and little................................. 5150
Ring and little................................. 5151
Single finger:
Thumb........................................... 5152
Index finger.................................... 5153
Long finger..................................... 5154
Ring finger..................................... 5155
Little finger................................... 5156
Forearm:
Above insertion of pronator teres............... 5123
Below insertion of pronator teres............... 5124
Leg:
With defective stump............................ 5163
Not improvable by prosthesis controlled by 5164
natural knee action............................
At lower level, permitting prosthesis........... 5165
Forefoot, proximal to metatarsal bones.......... 5166
Toes, all, amputation of, without metatarsal 5170
loss or transmetatarsal, amputation of, with up
to half of metatarsal loss.....................
Toe, great...................................... 5171
Toe, other than great, with removal metatarsal 5172
head...........................................
Toes, three or more, without metatarsal 5173
involvement....................................
Thigh:
Complete amputation, lower extremity............ 5160
Upper third..................................... 5161
Middle or lower thirds.......................... 5162

* * * * * * *
Arthritis:
Degenerative, other than post-traumatic......... 5003
Gonorrheal...................................... 5004
Other specified forms (excluding gout).......... 5009
Pneumococcic.................................... 5005
Post-traumatic.................................. 5010
Multi-joint (except post-traumatic and gout).... 5002
Streptococcic................................... 5008
Syphilitic...................................... 5007
Typhoid......................................... 5006
Arthropathy............................................. 5009

* * * * * * *
Bones:
Neoplasm, benign.................................... 5015
Neoplasm, malignant, primary or secondary........... 5012
Shortening of the lower extremity................... 5275

* * * * * * *
Colitis, ulcerative..................................... 7323
Compartment syndrome.................................... 5331

* * * * * * *
Dacryocystitis.......................................... 6031
Decompression illness................................... 5011

* * * * * * *
Hernia:
Femoral............................................. 7340
Hiatal.............................................. 7346
Inguinal............................................ 7338
Muscle.............................................. 5326
Ventral............................................. 7339
Heterotopic ossification................................ 5023

[[Page 35733]]

Hip:
Flail joint......................................... 5254

* * * * * * *
Hodgkin's disease....................................... 7709
Hydronephrosis.......................................... 7509

* * * * * * *
Myocardial infarction................................... 7006
Myositis................................................ 5021

* * * * * * *
Osteomalacia, residuals of.............................. 5014

* * * * * * *
Osteoporosis, residuals of.............................. 5013

* * * * * * *
Paralysis:
Accommodation....................................... 6030
Agitans............................................. 8004
Complete, traumatic................................. 5244

* * * * * * *
Pericarditis............................................ 7002
Peripheral vestibular disorders......................... 6204

* * * * * * *
Plague.................................................. 6307
Plantar fasciitis....................................... 5285

* * * * * * *
Prosthetic implants:
Ankle replacement................................... 5056
Elbow replacement................................... 5052
Hip, resurfacing or replacement..................... 5054
Knee, resurfacing or replacement.................... 5055

* * * * * * *
Retinitis............................................... 6006
Rhabdomyolysis, residuals of............................ 5330

* * * * * * *
Spinal stenosis......................................... 5238
Spine:
Degenerative arthritis, degenerative disc disease 5242
other than intervertebral disc syndrome............

* * * * * * *
Syndromes:
Chronic Fatigue Syndrome (CFS)...................... 6354
Cushing's........................................... 7907
Meniere's........................................... 6205
Raynaud's........................................... 7117
Sleep Apnea......................................... 6847
Syphilis................................................ 6310

* * * * * * *
Tenosynovitis, tendinitis, tendinosis or tendinopathy... 5024

* * * * * * *
------------------------------------------------------------------------

[FR Doc. 2017-15766 Filed 7-31-17; 8:45 am]
BILLING CODE 8320-01-P

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