Schedule for Rating Disabilities; The Digestive System, 39160-39184 [2011-15698]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 76, Number 128 (Tuesday, July 5, 2011)]
[Proposed Rules]
[Pages 39160-39184]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-15698]



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Vol. 76

Tuesday,

No. 128

July 5, 2011

Part II





Department of Veteran Affairs





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38 CFR Part 4





Schedule for Rating Disabilities; The Digestive System; Proposed Rule

Federal Register / Vol. 76 , No. 128 / Tuesday, July 5, 2011 / 
Proposed Rules

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AN12


Schedule for Rating Disabilities; The Digestive System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the 
portion of the Schedule for Rating Disabilities that addresses the 
Digestive System. The purpose of this change is to incorporate medical 
advances that have occurred since the last review, insert current 
medical terminology, and provide clear criteria.

DATES: Comments must be received by VA on or before September 6, 2011.

ADDRESSES: Written comments may be submitted through https://www.Regulations.gov; by mail or hand-delivery to the Director, 
Regulations Management (02REG), Department of Veterans Affairs, 810 
Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202) 
273-9026. Comments should indicate that they are submitted in response 
to RIN 2900-AN12-Schedule for Rating Disabilities; The Digestive 
System. 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 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 at https://www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Thomas J. Kniffen, Chief, Regulations 
Staff (211D), Compensation and Pension Service, Veterans Benefits 
Administration, Department of Veterans Affairs, 810 Vermont Avenue, 
NW., Washington, DC 20420, (202) 461-9725. (This is not a toll-free 
number.)

SUPPLEMENTARY INFORMATION: VA published an advance notice of proposed 
rulemaking in the Federal Register of May 2, 1991 (56 FR 20168), 
advising the public of our intent to revise and update the portion of 
the Schedule for Rating Disabilities (the rating schedule) that 
addresses the digestive system as well as to solicit and obtain 
comments and suggestions from interest groups and the general public. 
By revising the rating schedule, we aim to eliminate ambiguities, 
include medical conditions not currently in the rating schedule, and 
implement current medical criteria and terminology that reflect recent 
medical advances.

Comments in Response To Advance Notice of Proposed Rulemaking

    In response to the advance notice of proposed rulemaking, we 
received comments from the American Legion and from several VA 
employees. One commenter suggested that we add to the rating schedule 
Crohn's disease; esophageal spasm (with its own evaluation criteria); 
hepatitis A, B, and C; chronic inflammation of the liver and its 
residuals; and malabsorption due to pancreatic disease. We propose to 
address each of these conditions in this revision, except for hepatitis 
and chronic inflammation of the liver, which were addressed in a 
separate rulemaking on liver disabilities (66 FR 29486, May 31, 2001).
    The same commenter suggested we include reflux esophagitis with 
hiatal hernia, with the criteria taking into account a measurement of 
reflux. For esophageal abnormalities, reflux measurement (manometry), 
barium swallows, and esophagoscopy provide information about 
physiological and anatomical abnormalities, and may be useful for 
diagnosis and prognosis, for determining response to therapy, and to 
prepare for surgery. They are less useful, however, in assessing the 
level of disability than the severity of symptoms, the impact of the 
condition on the nutritional status of the patient, and the potential 
for remediation (``Disability Evaluation'' 379 (Stephen L. Demeter, 
M.D., Gunnar B.J. Anderson, M.D., and George M. Smith, M.D., 1996) and 
The Merck Manual 113 (18th ed. 2006)). While we propose to address 
reflux esophagitis in this revision, as discussed further below, we do 
not propose to use a measurement of reflux for evaluation.
    A second commenter suggested we add Crohn's disease and also revise 
the criteria for hemorrhoids. We propose to do both.
    One commenter suggested that we evaluate gastrectomy and vagotomy-
pyloroplasty under the same criteria. The major postoperative problem 
related to gastrectomy is dumping syndrome, which is the common term 
that refers to the group of symptoms that may occur following various 
types of surgery for ulcer disease. Many problems may be associated 
with vagotomy-pyloroplasty, of which dumping syndrome is only one. We 
therefore propose to retain separate evaluation criteria for these 
conditions, as discussed in more detail below.
    The same commenter suggested that we delete diagnostic codes 7201 
(lips, injuries of), 7205 (esophagus, diverticulum of, acquired), 7306 
(marginal ulcer), 7309 (stomach, stenosis of), 7310 (stomach, injury 
of, residuals), 7315 (chronic cholelithiasis), 7316 (chronic 
cholangitis), 7324 (distomiasis, intestinal or hepatic), and 7342 
(visceroptosis) because they are rare.
    We propose to remove diagnostic code 7342 (visceroptosis) because 
visceroptosis is an obsolete diagnosis, as discussed further below. 
However, we propose to retain all of the other diagnostic codes 
mentioned by the commenter, although some in a revised form, since some 
of them, such as diagnostic code 7315 (cholelithiasis), represent 
common digestive diseases, and others, such as those for injuries of 
the lips or stomach, may be the only appropriate codes under which to 
address injuries, including combat wounds, to those parts of the body. 
They may therefore be useful to VA for statistical purposes, as well as 
for rating purposes.
    Another commenter suggested we remove diagnostic code 7201 (lips, 
injuries of); add esophagitis, duodenitis, and Crohn's disease; provide 
a diagnostic code for total gastrectomy; add a 10-percent evaluation 
level for cirrhosis; provide evaluation criteria for ileostomy and 
colostomy; and provide objective evaluation criteria for pancreatitis. 
We have already discussed injuries of the lips, which we propose to 
retain. We otherwise propose to follow all of these suggestions, with 
two exceptions. First, we do not propose to add a diagnostic code for 
total gastrectomy, because that condition can be appropriately 
evaluated under an existing diagnostic code (7308, Postgastrectomy 
syndromes). Second, we have already added a 10-percent evaluation level 
for cirrhosis in the separate rulemaking that addressed disabilities of 
the liver (66 FR 29486, May 31, 2001), so there is no need for further 
action in this proposed rule based on that comment. This commenter also 
suggested we remove diagnostic codes 7342 (visceroptosis) and 7337 
(pruritus ani) and that we delete the word ``infectious'' from 
``infectious hepatitis.'' We also propose to remove diagnostic codes 
7342 and 7337. The suggested change concerning hepatitis was made in 
the separate rulemaking for liver disabilities, so there is no need for 
further action in this proposed rule.

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Outside Consultants

    In addition to publishing an advance notice of proposed rulemaking, 
VA contracted with an outside consulting firm for the purpose of 
gathering suggestions for changes in the rating schedule to help 
fulfill the goals of revising and updating the medical criteria. This 
proposed amendment includes many of their suggestions. Since one of the 
goals of the rating schedule revision is to eliminate ambiguities, we 
did not follow some of our consultants' recommendations that are based, 
at least, in part, on subjective or indefinite language when more 
objective terminology could be used. Furthermore, each group of 
consultants reviewed only one portion or body system of the rating 
schedule, and we had to assess the feasibility of their recommendations 
in light of the entire rating schedule, in order to assure internal 
consistency. Relevant recommendations from our consultants are 
discussed below.

Section 4.110

    Current Sec.  4.110, ``Ulcers,'' explains that ``the term `peptic 
ulcer' is not sufficiently specific for rating purposes'' because there 
are ``manifest differences'' between ulcers of the stomach or duodenum 
as compared to those at an anastomotic stoma, and that, therefore, the 
location of an ulcer should be identified in order to evaluate it. This 
material is unnecessary, since there are separate diagnostic codes for 
ulcers of the stomach, duodenum, and gastrojejunal area (or anastomotic 
stoma), and the rating schedule therefore makes it clear that the site 
of an ulcer must be identified in order to assign the correct 
diagnostic code. Furthermore, this section establishes no procedures 
that raters must follow in evaluating ulcer disease. We therefore 
propose to remove the material currently in Sec.  4.110, retitle this 
section ``Dyspepsia,'' and provide in it a definition of the term 
``dyspepsia'' for purposes of evaluating conditions in Sec.  4.114. We 
propose that Sec.  4.110 would define dyspepsia as any combination of 
the following symptoms: Gnawing or burning epigastric or substernal 
pain that may be relieved by food (especially milk) or antacids, 
nausea, vomiting, anorexia (lack or loss of appetite), abdominal 
bloating, and belching. It would also state that when there is 
obstruction of the outlet of the stomach (gastric outlet obstruction), 
dyspepsia may also include symptoms of gastroesophageal reflux (flow of 
stomach contents back into the esophagus), borborygmi (audible rumbling 
bowel sounds), crampy pain, and obstipation (severe constipation).

Section 4.111

    Current Sec.  4.111, ``Postgastrectomy syndromes,'' discusses 
dumping syndrome, a condition which is relevant only to diagnostic code 
7308, ``postgastrectomy syndromes,'' and we propose to list the 
symptoms of dumping syndrome in a note under that diagnostic code. We 
therefore propose to remove Sec.  4.111.

Section 4.112

    Current Sec.  4.112, ``Weight loss,'' defines ``substantial weight 
loss,'' ``minor weight loss,'' ``inability to gain weight,'' and 
``baseline weight,'' for purposes of evaluating conditions in Sec.  
4.114. Some of the revisions of conditions in Sec.  4.114 that we are 
proposing have evaluation criteria that are based in part on 
malnutrition, and there is no universally accepted definition of 
malnutrition. We, therefore, propose to provide a definition of 
malnutrition for purposes of evaluating conditions in Sec.  4.114 by 
expanding the title of Sec.  4.112 to ``Weight loss and malnutrition'' 
and adding the following definition: `` `malnutrition' means a 
deficiency state resulting from insufficient intake of one or multiple 
essential nutrients or the inability of the body to absorb, utilize, or 
retain such nutrients. It is characterized by failure of the body to 
maintain normal organ functions and healthy tissues.''

Section 4.113

    Current Sec.  4.113, ``Coexisting abdominal conditions,'' states 
that there are diseases of the digestive system that produce a common 
disability picture with similar symptoms and which should therefore not 
be rated separately, as this would be a violation of 38 CFR 4.14, 
``Avoidance of pyramiding'' (which states that the evaluation of the 
same disability under various diagnoses is to be avoided). Current 
Sec.  4.114, in an introductory paragraph, lists specific diagnostic 
codes that cannot be combined, and directs that a single evaluation 
``be assigned under the diagnostic code that reflects the predominant 
disability picture, with elevation to the next higher evaluation where 
the severity of the overall disability warrants such evaluation.'' In 
order to provide clear guidance about evaluation when there are two or 
more coexisting digestive conditions, we propose to revise the material 
in Sec. Sec.  4.113 and 4.114 related to this subject and place the 
revised directions in Sec.  4.113.
    We propose to direct the rater to separately evaluate two or more 
conditions in Sec.  4.114 only if the signs and symptoms attributed to 
each are separable, and if they are not separable, to assign a single 
evaluation under the diagnostic code that best allows evaluation of the 
overall functional impairment resulting from both conditions. With 
these instructions, the list of conditions that may not be combined, 
given in current Sec.  4.114, would be unnecessary, and we propose to 
remove it. This revision would provide a fair and equitable method of 
evaluation, and is not contrary to Sec.  4.14. In addition, it would 
remove the somewhat unclear direction to assign a diagnostic code that 
reflects the predominant disability and elevate to the next higher 
evaluation level ``where the severity of the overall disability 
warrants such elevation,'' a direction that could be interpreted 
differently by different individuals. We also propose to change the 
title of Sec.  4.113 to ``Evaluation of coexisting digestive 
conditions,'' since not all disabilities in this body system are 
abdominal, as the current title of Sec.  4.113 implies.

Section 4.114 Schedule of Ratings-Digestive System

Mouth injuries, Lip injuries, Tongue Injuries (Including Tongue Loss), 
Esophageal Stricture, Achalasia (Cardiospasm) and Other Motor Disorders 
of the Esophagus, and Esophageal Diverticula (Diagnostic Codes 7200-
7205)

    The current rating schedule directs that injuries of the mouth 
(diagnostic code 7200) be evaluated on the basis of disfigurement and 
impairment of masticatory function, and injuries of the lips 
(diagnostic code 7201) on the basis of disfigurement of the face. Both 
mouth and lip injuries are therefore evaluated using criteria under 
other diagnostic codes. Loss of whole or part of the tongue (diagnostic 
code 7202) is currently evaluated at 100 percent if there is inability 
to communicate by speech, at 60 percent if there is loss of one-half or 
more of the tongue, and at 30 percent if there is marked speech 
impairment. Findings in these three conditions sometimes overlap, 
according to our consultants, with the major problems being (1) 
Difficulty with mastication (chewing) or swallowing, causing a 
restriction of diet; (2) difficulty with speech; (3) loss of part of 
the tongue; and (4) disfigurement. We therefore propose to provide a 
general rating formula for the evaluation of residuals of mouth 
injuries, lip injuries,

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and tongue injuries, including tongue loss.
    In addition, there are several esophageal abnormalities with signs 
and symptoms that are similar to one another, and that also overlap the 
findings in mouth, lip, and tongue injuries. For these reasons, we 
propose to include several esophageal conditions in the same general 
rating formula for this whole group of conditions, as discussed in more 
detail below. Our consultants recommended that there be a 10-percent 
evaluation level for each of these disabilities, and also pointed out 
that stricture of the esophagus, for example, can be totally disabling. 
We agree, and propose to provide evaluation levels of 100, 60, 30, and 
10 percent in this general rating formula.
    Stricture of the esophagus (diagnostic code 7203) is currently 
evaluated at 80 percent if it permits ``passage of liquids only, with 
marked impairment of general health;'' at 50 percent if it is ``severe, 
permitting liquids only;'' and at 30 percent if it is ``moderate.'' 
These criteria contain subjective terms such as ``marked,'' 
``moderate,'' and ``severe,'' which could be interpreted differently by 
different individuals. The general rating formula we are proposing for 
the evaluation of this and other related conditions with symptoms in 
common would provide more objective criteria.
    Spasm of the esophagus (cardiospasm) (diagnostic code 7204) is 
currently evaluated based on the degree of obstruction (stricture), if 
not amenable to dilation. We propose to update the title of diagnostic 
code 7204 from ``cardiospasm'' to ``achalasia,'' the current term for 
this condition. Achalasia is a condition in which, upon swallowing, 
there is a failure of relaxation of the lower esophageal sphincter (at 
the junction of the esophagus and stomach). We also propose to include 
in this diagnostic code other related motor disorders of the esophagus 
with impairment in the normal passage of food through the esophagus due 
to muscle or nerve abnormalities, by revising the title to ``Achalasia 
(cardiospasm) and other motor disorders of the esophagus (diffuse 
esophageal spasm, corkscrew esophagus, nutcracker esophagus, etc.).'' 
Our consultants suggested we provide one diagnostic code for achalasia, 
with 100- and 30-percent evaluation levels, and another for other 
esophageal motor disorders, with 50-, 30-, and 10-percent evaluation 
levels. However, the signs and symptoms of these conditions are very 
similar, and the severity of disability from any one of these 
conditions varies widely from individual to individual. Therefore, in 
our judgment, it is feasible and preferable to provide a single 
diagnostic code with a broad range of evaluations (100 to 10 percent), 
for the sake of promoting more consistent and appropriate evaluations.
    Acquired diverticulum of the esophagus (diagnostic code 7205) is 
currently evaluated as obstruction (stricture). We propose to revise 
the title of diagnostic code 7205 from ``Esophagus, diverticulum of'' 
to ``Esophageal diverticula, including pharyngoesophageal (Zenker's), 
midesophageal, and epiphrenic types'' to indicate more clearly the 
several types of diverticula that may warrant evaluation under this 
diagnostic code. Achalasia and esophageal diverticulum result in 
impairments similar to one another, and there is overlap with 
impairments resulting from mouth, lip, and tongue injuries. In 
addition, esophageal stricture, achalasia, and esophageal diverticulum 
may all result in pulmonary aspiration (inhaling food or liquid into 
the lungs) due to regurgitation or vomiting and may require treatment 
with prescription medication to control symptoms. Esophageal dilation 
may be required for stricture or achalasia. We therefore propose to 
include criteria for these esophageal conditions, as well as mouth, 
lip, and tongue injuries, in a general rating formula that encompasses 
the main signs and symptoms of all.
    We propose to title the general rating formula for this group of 
conditions as follows: ``General Rating Formula for Residuals of mouth 
injuries (diagnostic code 7200), Residuals of lip injuries (diagnostic 
code 7201), Residuals of tongue injuries, including tongue loss 
(diagnostic code 7202), Esophageal stricture (diagnostic code 7203), 
Achalasia (cardiospasm) and other motor disorders of the esophagus 
(diagnostic code 7204), and Esophageal diverticula (diagnostic code 
7205).'' We propose to base evaluation of these conditions on the 
extent of limitation of diet, on the extent of the ability to speak 
clearly enough to be understood, on the frequency of episodes of 
pulmonary aspiration due to regurgitation or vomiting, and on whether 
or not continuous treatment with prescription medication is required. 
We propose to provide a list of findings at each evaluation level, any 
of which would warrant that percentage of evaluation.
    We propose a 100-percent evaluation for any of the following: Tube 
feeding required; diet restricted to liquid foods, with substantial 
weight loss, malnutrition, and anemia; four or more episodes per year 
of pulmonary aspiration (with bronchitis, pneumonia, or pulmonary 
abscess) due to regurgitation or vomiting; or inability to speak 
clearly enough to be understood. We propose a 60-percent evaluation for 
any of the following: Diet restricted to liquid and soft solid foods, 
with substantial weight loss or anemia; two to three episodes per year 
of pulmonary aspiration (with bronchitis, pneumonia, or pulmonary 
abscess) due to regurgitation or vomiting; or inability to speak 
clearly enough to be understood at least half of the time but not all 
of the time. We propose a 30-percent evaluation for any of the 
following: Diet restricted to liquid and soft solid foods, with minor 
weight loss; esophageal dilation carried out five or more times per 
year; daily regurgitation or vomiting; one episode per year of 
pulmonary aspiration (with bronchitis, pneumonia, or pulmonary abscess) 
due to regurgitation or vomiting; or inability to speak clearly enough 
to be understood at times, but less than half of the time. We propose a 
10-percent evaluation for any of the following: Diet restricted to 
liquid and soft solid foods; esophageal dilation carried out one to 
four times per year; heartburn (pyrosis) requiring continous treatment 
with prescription and at least one of the following other symptoms: 
Retrosternal chest pain, difficulty swallowing (dysphagia), or pain 
during swallowing (odynophagia); partial tongue loss; or impaired 
articulation for some words, but speech understandable.
    We also propose to add a note directing raters to separately 
evaluate mouth and lip injuries under diagnostic code 7800 (Burn 
scar(s) of the head, face, or neck; scar(s) of the head, face, or neck 
due to other causes; or other disfigurement of the head, face, or 
neck), if applicable, and to combine this with an evaluation under this 
general rating formula, under the provisions of Sec.  4.25.
    The proposed general rating formula for these conditions is broad 
enough to encompass any degree of severity of the major types of 
impairment from any of these conditions, and from combined injuries of 
more than one of these structures. It also provides more objective 
criteria than the current schedule because it excludes subjective 
descriptors like ``marked'' and more sharply defines the extent of 
speech impairment and dietary limitations required for various 
evaluations. Evaluations should, therefore, be more consistent. 
Although our consultants used subjective terms such as ``moderate'' and 
``severe'' in their recommended criteria, we are proposing to exclude 
such terms whenever possible throughout the revision of the

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rating schedule, for the sake of promoting consistent evaluations. Our 
consultants also included the nebulous phrase ``interfering with normal 
daily functioning,'' which could be subject to different 
interpretations by different people, and we do not propose to use this 
language. However, the criteria are otherwise substantially the same as 
those our consultants recommended.

Salivary Gland Disease (Diagnostic Code 7207)

    Since there is no current diagnostic code under which salivary 
gland disease can be appropriately evaluated, and it is a common enough 
disability in veterans to require evaluation, we propose to add 
diagnostic code 7207, ``Salivary gland (parotid, submandibular, 
sublingual) disease other than neoplasm.'' We propose that there be 20-
, 10-, and zero-percent evaluation levels, based on the presence of 
xerostomia (dry mouth) and its effects, chronic inflammation or 
swelling of a salivary gland, salivary gland calculi or stricture, 
increase in dental caries, and weight loss, because these are the major 
impairments that may result from salivary gland disease (``Textbook of 
Gastroenterology'' 225 (Tadataka Yamada, M.D., ed., 1991)).
    We propose a 20-percent evaluation for xerostomia (dry mouth) with 
altered sensation of taste and difficulty with lubrication and 
mastication of food resulting in either weight loss or increase in 
dental caries; a 10-percent evaluation for xerostomia with altered 
sensation of taste and difficulty with lubrication and mastication of 
food, but without weight loss or increase in dental caries; chronic 
inflammation of a salivary gland with pain and swelling on eating; one 
or more salivary calculi; or a salivary gland stricture. We propose a 
zero-percent evaluation for either xerostomia without difficulty in 
mastication of food, or painless swelling of the salivary gland. We are 
proposing a zero-percent evaluation level in order to make it clear 
that these findings warrant a zero-, rather than a ten-percent 
evaluation when it might otherwise be unclear to the rater.
    We also propose to provide note (1) directing that facial nerve 
(cranial nerve VII) impairment, which may result from parotid gland 
disease or its treatment, be evaluated under diagnostic code 8207 
(cranial nerve VII) and that any disfigurement due to facial swelling 
be evaluated under diagnostic code (Burn scar(s) of the head, face, or 
neck; scar(s) of the head, face, or neck due to other causes; or other 
disfigurement of the head, face, or neck). We propose to add note (2) 
to explain what Sjogren's syndrome is and how it should be evaluated. 
It is an autoimmune disorder that causes xerostomia (dry mouth) and 
keratoconjunctivitis sicca (dry eyes) and may affect other parts of the 
body. The note directs that the effects of xerostomia (dry mouth) due 
to Sjogren's syndrome be evaluated under diagnostic code 7207, 
keratoconjunctivitis sicca under the portion of the rating schedule 
that addresses Organs of Special Sense, and other effects of the 
syndrome, if any, on other body parts under appropriate diagnostic 
codes in other sections of the rating schedule.

Peritoneal Adhesions (Diagnostic Code 7301)

    Peritoneal adhesions, diagnostic code 7301, are currently evaluated 
at levels of 50, 30, 10, or zero percent. A 50-percent evaluation is 
assigned if adhesions are severe, with ``definite partial obstruction 
shown by X-ray, with frequent and prolonged episodes of severe colic 
distention, nausea or vomiting, following severe peritonitis, ruptured 
appendix, perforated ulcer, or operation with drainage.'' A 30-percent 
evaluation is assigned if adhesions are moderately severe, with 
``partial obstruction manifested by delayed motility of barium meal and 
less frequent and less prolonged episodes of pain.'' A 10-percent 
evaluation is assigned if adhesions are moderate, with ``pulling pain 
on attempting work or aggravated by movements of the body, or 
occasional episodes of colic pain, nausea, constipation (perhaps 
alternating with diarrhea) or abdominal distention.'' A zero-percent 
evaluation is assigned if adhesions are ``mild.'' Subjective adjectives 
such as ``mild,'' ``moderate,'' ``moderately severe,'' and ``severe'' 
are used at each level.
    We propose to provide evaluation levels of 60, 30, or 10 percent 
for peritoneal adhesions, based primarily on the number of episodes of 
partial intestinal obstruction with typical symptoms, which may 
include, but are not limited to colicky abdominal pain, abdominal 
distention, borborygmi (audible rumbling bowel sounds), nausea, 
vomiting, and obstipation (severe constipation) (Yamada, 719). X-ray 
confirmation of a partial bowel obstruction would be required for any 
level of evaluation.
    We propose a 60-percent evaluation for six or more episodes per 
year of partial obstruction of the bowel (confirmed by X-ray), with 
typical signs and symptoms (which may include, but are not limited to 
colicky abdominal pain, abdominal distention, borborygmi (audible 
rumbling bowel sounds), nausea, vomiting, and obstipation) (severe 
constipation)); a 30-percent evaluation for three to five episodes per 
year of partial obstruction of the bowel, with typical signs and 
symptoms; and a 10-percent evaluation for either of the following: One 
or two episodes per year of partial obstruction of the bowel, with 
typical signs and symptoms, or, in the absence of such episodes, 
pulling pain on body movement, if not attributable to another 
condition.
    These criteria are in general agreement with those recommended by 
our consultants, but they exclude subjective terms such as 
``frequent,'' ``occasional,'' and ``severe'' that the consultants 
suggested, in favor of more objective criteria in order to promote 
consistent evaluations.
    A current note following diagnostic code 7301 states that ratings 
for adhesions will be considered when there is a history of operative 
or other traumatic or infectious (intraabdominal) process and at least 
two of the following: Disturbance of motility, actual partial 
obstruction, reflex disturbances, or presence of pain. We propose to 
revise this note to state that evaluation under diagnostic code 7301 
requires a history of abdominal or pelvic surgery, infection, 
irradiation, trauma, or other known etiology for peritoneal adhesions. 
We propose to add a second note listing the typical signs and symptoms 
of partial bowel obstruction, for purposes of evaluation under 
diagnostic code 7301. This would simplify the evaluation criteria by 
eliminating the need to repeat the list of symptoms at each level. Our 
consultants recommended that we provide a note similar to the current 
note, with both causes and symptoms of adhesions listed, and we have 
basically done this, but divided the material into two notes, for the 
sake of clarity.

General Rating Formula for Ulcer Disease (Diagnostic Codes 7304-7306)

    There are currently three diagnostic codes for ulcers: diagnostic 
code 7304 for gastric ulcers, diagnostic code 7305 for duodenal ulcers, 
and diagnostic code 7306 for marginal (gastrojejunal) ulcers. No 
specific evaluation criteria are provided for gastric ulcers, but they 
are ordinarily rated under the criteria for duodenal ulcers. Duodenal 
ulcers are currently evaluated at levels of 60, 40, 20, or 10 percent. 
A 60-percent evaluation is assigned if the condition is severe, with 
pain only partially relieved by ulcer therapy, and there is periodic 
vomiting, recurrent hematemesis or melena, with manifestations of 
anemia and weight loss, productive of definite impairment of health. A 
40-percent evaluation is assigned if the condition is moderately 
severe, meaning that it is

[[Page 39164]]

less than severe but with impairment of health manifested by anemia and 
weight loss, or that there are recurrent incapacitating episodes 
averaging 10 days or more in duration at least four or more times a 
year. A 20-percent evaluation is assigned if the condition is moderate, 
with recurring episodes of severe symptoms two or three times a year 
averaging 10 days in duration, or with continuous moderate 
manifestations. A 10-percent evaluation is assigned if the condition is 
mild, with recurring symptoms once or twice yearly.
    Marginal ulcers are currently evaluated under a separate set of 
criteria that are similar to those for duodenal ulcer, except that 
there is also a 100-percent evaluation level, to be assigned if the 
condition is pronounced, with periodic or continuous pain unrelieved by 
standard ulcer therapy with periodic vomiting, recurring melena or 
hematemesis, and weight loss, and the condition is totally 
incapacitating. A 60-percent evaluation is assigned if the condition is 
severe, with symptoms of the same type as pronounced but less 
pronounced and less continuous, with definite impairment of health. A 
40-percent evaluation is assigned if the condition is moderately 
severe, with intercurrent episodes of abdominal pain at least once a 
month partially or completely relieved by ulcer therapy, or there are 
mild and transient episodes of vomiting or melena. A 20-percent 
evaluation is assigned if the condition is moderate, with episodes of 
recurring symptoms several times a year. A 10-percent evaluation is 
assigned if the condition is mild, with brief episodes of recurring 
symptoms once or twice yearly. Both sets of criteria for rating ulcer 
disease use subjective adjectives such as ``mild,'' ``moderate,'' and 
``pronounced'' throughout the formulas.
    Our consultants pointed out that while ulcers may vary in location, 
they produce the same array of symptoms, and do not differ in 
functional impairment. They suggested that all types of ulcers be 
evaluated under the same criteria: the presence of symptoms and their 
response or lack of response to treatment, the extent of incapacitating 
or recurring episodes, and whether there is recurrent hematemesis 
(vomiting blood) or melena, anemia, or weight loss. We propose to 
adopt, with some modifications, their recommendations regarding bases 
of evaluations and to evaluate all types of ulcer disease under the 
same criteria. We propose to provide a single rating formula for 
gastric ulcer (diagnostic code 7304), duodenal ulcer (diagnostic code 
7305), and marginal (gastrojejunal) ulcer (diagnostic code 7306), based 
on the recommended criteria. We also propose to change the title of 
diagnostic code 7305 to ``duodenal ulcer or duodenitis'' in order to 
include duodenitis under this code, because these conditions commonly 
occur together and result in similar findings. We propose to provide 
evaluation levels of 100, 60, 30, and 10 percent. Our consultants 
suggested 60 percent as the highest level of evaluation, but, because 
our experience has shown that a number of veterans are totally disabled 
by severe ulcer disease, we propose to add a 100-percent level. These 
levels also differ from the current schedule by substituting a 30-
percent level for the current 20- and 40-percent levels. This change 
will provide a clearer distinction between the 10-percent level and the 
next higher level (which we propose to be 30 percent instead of 20 
percent), a factor that will promote more consistent evaluations, and 
will still be sufficient to accommodate the range of severity of ulcer 
disease.
    We propose a 100-percent evaluation for either substantial weight 
loss, malnutrition, and anemia due to gastrointestinal bleeding; or for 
hospitalization three or more times per year for vomiting, refractory 
pain, gastrointestinal bleeding, perforation, obstruction, or 
penetration to liver, pancreas, or colon. We propose a 60-percent 
evaluation for either periodic or constant dyspepsia with substantial 
weight loss and anemia due to ulcer disease; or for hospitalization two 
times per year for vomiting, refractory pain, gastrointestinal 
bleeding, perforation, obstruction, or penetration to liver, pancreas, 
or colon. We propose a 30-percent evaluation for either periodic or 
constant dyspepsia with at least minor weight loss; or for 
hospitalization once per year for vomiting, refractory pain, 
gastrointestinal bleeding, perforation, obstruction, or penetration to 
liver, pancreas, or colon. We propose a 10-percent evaluation for 
recurring dyspepsia that requires continuous treatment with 
prescription medication for control.
    We also propose to add a note under the general rating formula for 
ulcer disease stating that the diagnosis of ulcer disease or duodenitis 
requires confirmation on at least one occasion by imaging or endoscopy. 
Because the symptoms of ulcer disease are not specific, the note would 
assure that the diagnosis of ulcer disease is not based on symptoms 
alone.

Chronic Gastritis (Diagnostic Code 7307)

    We propose to revise the title of diagnostic code 7307 from the 
current ``gastritis, hypertrophic (identified by gastroscope)'' to 
``chronic gastritis (including but not limited to erosive, 
hypertrophic, hemorrhagic, bile reflux, alcoholic, and drug-induced 
gastritis)'' to indicate that there are several types of gastritis that 
may be evaluated under this code.
    Gastritis is an inflammation of the gastric (stomach) mucosa. 
Common causes include Helicobacter pylori infection, non-steroidal 
anti-inflammatory drugs, alcohol, stress, and autoimmune phenomena 
(atrophic gastritis) (Merck, 117). While chronic gastritis is often 
asymptomatic (symptom-free), it may cause dyspepsia and sometimes 
gastro-intestinal bleeding with resulting anemia. A rare type of 
gastritis results in protein-losing gastropathy (disease of the 
stomach), in which hypoalbuminia (low albumin level in blood), 
diarrhea, weight loss, and edema may occur. Gastritis is currently 
evaluated at 60, 30, or 10 percent, with a 60-percent evaluation 
assigned when the condition is chronic, with severe hemorrhages or 
large ulcerated or eroded areas; a 30-percent evaluation when the 
condition is chronic, ``with multiple small eroded or ulcerated areas, 
and symptoms;'' and a 10-percent evaluation when the condition is 
chronic, ``with small nodular lesions, and symptoms.'' We propose to 
continue these evaluation levels, but to provide different criteria, 
based more on objective clinical findings, which are common indicators 
of disability, than on the pathologic appearance of the gastric mucosa.
    We propose a 60-percent evaluation for any of the following: 
Periodic or continuous dyspepsia with anemia due to gastrointestinal 
bleeding; protein-losing gastropathy with substantial weight loss and 
peripheral edema; or hospitalization two or more times per year for 
gastrointestinal bleeding, intractable vomiting, or other complication 
of chronic gastritis. We propose a 30-percent evaluation for either of 
the following: Protein-losing gastropathy with at least minor weight 
loss, or hospitalization once per year for gastrointestinal bleeding, 
intractable vomiting, or other complication of chronic gastritis. We 
propose a 10-percent evaluation for dyspepsia that requires continuous 
treatment with prescription medication.
    These proposed criteria are similar to those recommended by our 
consultants, but have been modified to remove

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subjective terms, and for the sake of internal consistency. In order to 
document that gastritis, which is often hard to diagnose, is definitely 
present, we also propose to add a note stating that evaluation under 
diagnostic code 7307 requires that the diagnosis of chronic gastritis 
be confirmed on at least one occasion by endoscopy. The condition of 
``gastritis, atrophic'' is listed in the current schedule at the end of 
the criteria for hypertrophic gastritis. It is followed by a statement 
that this is ``a complication of a number of diseases, including 
pernicious anemia,'' and a direction to rate the underlying condition. 
We propose to include this information in a second note under 
diagnostic code 7307, to provide clear guidance to the raters on how to 
evaluate atrophic gastritis.

Postgastrectomy Syndromes (Diagnostic Code 7308)

    Postgastrectomy syndromes (diagnostic code 7308) are currently 
evaluated at levels of 60, 40, or 20 percent, based on frequency of 
episodes of symptoms. A 60-percent evaluation is assigned when the 
condition is severe, meaning that it is associated with nausea, 
sweating, circulatory disturbance after meals, diarrhea, hypoglycemic 
symptoms, and weight loss with malnutrition and anemia; a 40-percent 
evaluation when the condition is moderate, with less frequent episodes 
of epigastric disorders with characteristic mild circulatory symptoms 
after meals but with diarrhea and weight loss; and a 20-percent 
evaluation when the condition is mild, with infrequent episodes of 
epigastric distress with characteristic mild circulatory symptoms or 
continuous mild manifestations.
    We propose to base evaluations of postgastrectomy syndromes on more 
objective criteria, such as the frequency of dumping syndrome (which is 
the common term for the group of symptoms that may occur following 
various types of surgery for ulcer disease), whether there is weight 
loss, malnutrition or anemia, and whether a restricted diet is needed. 
For the sake of simplicity, we propose to list the possible signs and 
symptoms of postgastrectomy syndromes in a note rather than listing all 
possible manifestations at every evaluation level.
    Several types of problems may occur after gastrectomy, with the 
onset, frequency, and types of symptoms varying with the particular 
type of surgery performed (Merck, 123). One problem is the dumping 
syndrome. There are two types of dumping syndrome, an early type that 
occurs within 30 minutes of eating, and a late type that occurs 90 
minutes to 3 hours after eating (``Harrison's Principles of Internal 
Medicine'' 1240 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)). 
Although early and late types have different causes, their symptoms 
overlap. Rather than experiencing a dumping syndrome, some individuals 
experience only severe diarrhea as a major postgastrectomy problem. 
Others experience abdominal pain, bilious vomiting (vomiting of bile), 
anemia, and weight loss due to a condition called alkaline reflux 
gastritis (also called biliary gastritis or bile reflux gastritis); and 
some individuals have malabsorption and poor absorption of vitamins and 
minerals resulting in malnutrition and anemia as their most significant 
problems (Yamada, 1394).
    Since the signs and symptoms of these postgastrectomy syndromes 
overlap, and ``dumping syndrome'' is the commonly used designation for 
postgastrectomy signs and symptoms, we propose to lump the various 
postgastrectomy syndromes together as ``dumping syndrome'' and to add a 
note under diagnostic code 7308 stating that for purposes of evaluation 
under diagnostic code 7308, the term ``dumping syndrome'' includes 
symptoms that are associated with any of the following postgastrectomy 
syndromes: Early and late types of dumping syndrome, postgastrectomy 
diarrhea, and alkaline reflux gastritis. These symptoms include any 
combination of weakness, dizziness, lightheadedness, diaphoresis 
(sweating), palpitations, tachycardia, postural hypotension, confusion, 
syncope (fainting), nausea, vomiting (often with bile), diarrhea, 
steatorrhea (fatty stools), borborygmi (audible rumbling bowel sounds), 
abdominal pain, anorexia (lack or loss of appetite), abdominal 
bloating, and belching. In order to include both types of 
postgastrectomy dumping syndromes, we also propose to state, in the 
same note, that symptoms may occur immediately after eating or up to 
three hours later.
    We propose to provide evaluation levels of 100, 60, 30, and 10 
percent, instead of the current 60, 40, and 20 percent. Our consultants 
suggested that we add a 100-percent evaluation level, since 
postgastrectomy syndromes may be severely disabling, and we propose to 
do so. As with gastritis, to promote consistent evaluations, we propose 
to substitute a 30-percent evaluation level for the 20- and 40-percent 
levels to provide a clearer distinction between adjacent levels. We 
also propose to add a 10-percent evaluation level for milder cases of 
dumping syndrome. We propose a 100-percent evaluation for dumping 
syndrome that occurs after most meals, with substantial weight loss, 
malnutrition, and anemia. We propose a 60-percent evaluation for 
dumping syndrome that occurs after most meals, with substantial weight 
loss and anemia. We propose a 30-percent evaluation for dumping 
syndrome that occurs daily or nearly so, despite treatment, with at 
least minor weight loss. We propose a 10-percent evaluation for 
intermittent dumping syndrome (occurring at least three times a week) 
requiring dietary restrictions.
    Our consultants suggested criteria that retain the same subjective 
terms of ``infrequent,'' ``mild,'' and ``less frequent,'' as the 
current schedule. For example, our consultants recommended that a 20-
percent evaluation be assigned for post-gastrectomy syndrome that is 
``mild'' with ``infrequent'' episodes of epigastric distress with 
``characteristic mild'' circulatory symptoms or continuous ``mild'' 
manifestations. We propose to use more specific terms such as ``after 
most meals'' and ``daily or nearly so,'' since making the criteria less 
ambiguous is one of the goals of the revision of the rating schedule. 
In order to make the criteria clear to everyone who uses the rating 
schedule, we propose to list the actual symptoms (many of which 
overlap) of hypoglycemia and circulatory disturbance in the note 
defining dumping syndrome, rather than use less clear terms such as 
``hypoglycemic symptoms'' or ``circulatory symptoms,'' as the 
consultants suggested. We also propose a second note to direct raters 
to separately evaluate complications, such as osteomalacia, under an 
appropriate diagnostic code.

Gastric Emptying Disorders (Diagnostic Code 7309)

    Diagnostic code 7309 is currently titled ``stomach, stenosis of'' 
and includes an instruction to ``[r]ate as for gastric ulcer'' 
(diagnostic code 7304), which in turn is usually rated as duodenal 
ulcer (diagnostic code 7305). We propose to make diagnostic code 7309 
more inclusive by changing the title to ``gastric emptying disorders 
(including gastroparesis (delayed gastric emptying), and pyloric, 
gastric, and other motility disturbances)'' because all of these 
conditions, which are not uncommon and are not currently listed in the 
current rating schedule, may produce similar signs and symptoms.
    We propose to provide evaluation levels of 100, 60, 30, and 10 
percent for diagnostic code 7309. As our consultants pointed out, these 
conditions can be very debilitating. We

[[Page 39166]]

propose to base the evaluation on criteria specific to gastric emptying 
disorders--epigastric pain or fullness, anorexia (lack or loss of 
appetite), nausea, vomiting, gastroesophageal reflux, early satiety 
(feeling that hunger and thirst are satisfied), and abdominal bloating 
(Yamada, 1264). We propose to add a note listing the signs and symptoms 
of gastric emptying disorders, for purposes of evaluation under 
diagnostic code 7309.
    We propose a 100-percent evaluation for daily or near-daily signs 
and symptoms with substantial weight loss and malnutrition. We propose 
a 60-percent evaluation for periodic or daily or near-daily signs and 
symptoms with substantial weight loss. We propose a 30-percent 
evaluation for periodic signs and symptoms with minor weight loss. We 
propose a 10-percent evaluation for periodic signs and symptoms without 
weight loss, but requiring continuous treatment with prescription 
medication. These criteria are specific to the disability and are 
clearer and more objective than those proposed by our consultants. 
While the consultants used similar symptoms, they also included 
modifiers like ``pronounced,'' ``severe,'' and ``moderate,'' which are 
subjective terms that we are trying to exclude from the rating schedule 
when possible, for the sake of consistent evaluations.

Injury of the Stomach (Diagnostic Code 7310)

    Injury of the stomach, diagnostic code 7310, is currently evaluated 
under the criteria for peritoneal adhesions (diagnostic code 7301). We 
propose to retain that direction and to add an alternative direction, 
as recommended by our consultants, to evaluate as postgastrectomy 
syndromes (diagnostic code 7308) if the injury required a gastric 
resection.

Liver Disease

    In a separate rulemaking, we previously revised the portion of 
Sec.  4.114 that addresses liver disease, including injury of the liver 
(diagnostic code 7311), cirrhosis of the liver (diagnostic code 7312), 
deletion of residuals of abscess of liver (diagnostic code 7313), 
infectious hepatitis (diagnostic code 7345), benign new growths of the 
digestive system (7344), and malignant new growths of the digestive 
system, exclusive of skin growths (diagnostic code 7343). Following 
notice and comment, this rulemaking was published as a final rule on 
May 31, 2001 (66 FR 29486). We do not propose any further changes to 
those diagnostic codes.

Biliary Tract Disease or Injury (Diagnostic Code 7314)

    Diagnostic code 7314 is currently titled ``cholecystitis, chronic'' 
and has evaluation levels of 30, 10, and zero percent. A 30-percent 
evaluation is assigned if the condition is severe, with frequent 
attacks of gall bladder colic; a 10-percent evaluation if the condition 
is moderate, with gall bladder dyspepsia, confirmed by X-ray technique, 
and with infrequent attacks (not over two or three a year) of gall 
bladder colic, with or without jaundice; and a zero-percent evaluation 
if the condition is mild.
    Chronic cholelithiasis (diagnostic code 7315) and chronic 
cholangitis (diagnostic code 7316) are evaluated under the same 
criteria as chronic cholecystitis. All of these conditions are closely 
related and may co-exist, and can readily be evaluated under a single 
diagnostic code and set of evaluation criteria. In addition, diagnostic 
code 7318, ``Gall bladder, removal of,'' can result in signs and 
symptoms similar to those of the above three conditions. It is 
currently evaluated at 30, 10, or zero percent, under subjectively-
defined criteria. A 30-percent evaluation is assigned if there are 
``severe symptoms,'' a 10-percent evaluation if there are ``mild 
symptoms,'' and a zero-percent evaluation if the condition is 
nonsymptomatic. ``Gall bladder, injury of'' (diagnostic code 7317) is 
currently rated as peritoneal adhesions.
    We, therefore, propose to revise the title of diagnostic code 7314 
to the more inclusive ``Biliary tract disease or injury (chronic 
cholecystitis, cholelithiasis, choledocholithiasis, chronic 
cholangitis, status post-cholecystectomy, gall bladder or bile duct 
injury, biliary dyskinesia, cholesterolosis, polyps of gall bladder, 
sclerosing cholangitis, stricture or infection of the bile ducts, 
choledochal cyst)'' because all of these conditions are related and may 
produce similar effects. It is therefore appropriate to evaluate them 
under the same criteria. It is not uncommon for more than one of these 
conditions to be present at the same time, and using a single set of 
criteria would better allow an appropriate overall evaluation in those 
cases, since the signs and symptoms overlap and may be identical. Our 
consultants did not suggest combining these conditions under a single 
diagnostic code, as we are proposing, but did suggest evaluating them 
under the same criteria. The evaluation criteria we are proposing are 
similar to those they suggested, but would eliminate the subjective 
terms ``severe,'' ``moderate'' and ``mild''.
    Although the current evaluation levels for these conditions are 
limited to 30, 10, and zero percent, we propose to provide evaluation 
levels of 100, 60, 30, and 10 percent for biliary tract disease or 
injury, to accommodate more severe cases, including those that are 
totally disabling. We propose to base evaluations on the frequency of 
acute attacks of signs and symptoms of biliary tract disease or injury 
per year; the frequency of hospitalizations for biliary tract disease 
or injury per year; the response to medical or surgical treatment; and 
whether liver failure is present. We propose to describe the usual 
signs and symptoms of biliary tract disease and injury in a note, as 
discussed below.
    We propose a 100-percent evaluation for any of the following: Near-
constant debilitating attacks of biliary tract disease or injury that 
are refractory to medical or surgical treatment; liver failure; or 
hospitalization three or more times per year for biliary tract disease 
or injury. We propose a 60-percent evaluation for either of the 
following: Six or more attacks of biliary tract disease or injury per 
year, partially responsive to treatment; or hospitalization two times 
per year for biliary tract disease or injury. We propose a 30-percent 
evaluation for either of the following: Three to five attacks of 
biliary tract disease or injury per year, or hospitalization once per 
year for biliary tract disease or injury. We propose a 10-percent 
evaluation for either of the following: One or two attacks of biliary 
tract disease or injury per year; or biliary tract pain occurring at 
least monthly, despite medical treatment. We propose to remove the 
zero-percent level as unnecessary (see Sec.  4.31).
    The proposed criteria would provide more objective criteria for 
evaluating these conditions and also provide a wider range of 
percentage evaluations, consistent with the potential disabling effects 
of these conditions.
    We propose to add four notes under diagnostic code 7314, with the 
first stating that for purposes of evaluation under diagnostic code 
7314, attacks of biliary tract disease or injury include any 
combination of such signs and symptoms as abdominal pain (including 
biliary colic), dyspepsia, jaundice, anorexia (lack or loss of 
appetite), nausea, vomiting, chills, and fever (Merck, 242-245). So 
that the presence of biliary tract disease is substantiated, and not 
based on symptoms alone, the second proposed note would state that 
evaluation under diagnostic code 7314 requires that the diagnosis of 
any of these conditions be confirmed by X-ray

[[Page 39167]]

or other imaging procedure, laboratory findings, or other objective 
evidence. The third proposed note would direct raters to separately 
evaluate peritoneal adhesions (diagnostic code 7301) if applicable, and 
combine (under the provisions of Sec.  4.25) with an evaluation under 
diagnostic code 7314, as long as the same findings are not used to 
support more than one evaluation. This would assure that traumatic or 
postoperative manifestations due to adhesions would be properly 
evaluated. The fourth proposed note would direct raters to evaluate the 
cirrhotic phase of sclerosing cholangitis under diagnostic code 7312 
(cirrhosis of liver), a more appropriate diagnostic code for evaluating 
that condition than 7314.
    Since chronic cholelithiasis (current diagnostic code 7315), 
chronic cholangitis (current diagnostic code 7316), injury of gall 
bladder (current diagnostic code 7317), and removal of gall bladder 
(current diagnostic code 7318) would all be included in diagnostic code 
7314, for reasons discussed above, we propose to delete the separate 
diagnostic codes for those conditions.

Disease or Injury of the Spleen

    There is currently a reference to disease or injury of the spleen 
under diagnostic code 7318, directing raters to the hemic and lymphatic 
systems. We propose to remove that reference as unnecessary, since the 
spleen, although in the abdominal cavity, is part of the lymphatic, not 
the digestive system. Evaluation criteria for splenectomy (diagnostic 
code 7706) and healed injury of the spleen (diagnostic code 7707) are 
included in the hemic and lymphatic portion of the rating schedule (38 
CFR 4.117), and both conditions are listed in the index to the rating 
schedule as part of the hemic and lymphatic systems.

Irritable Bowel Syndrome (Diagnostic Code 7319)

    Diagnostic code 7319 is currently titled ``Irritable colon syndrome 
(spastic colitis, mucous colitis, etc.).'' We propose to retitle it 
``Irritable bowel syndrome (irritable colon, spastic colitis, mucous 
colitis),'' since this is current terminology for the condition. The 
current evaluation levels are 30, 10, and zero percent. A 30-percent 
evaluation is assigned if the condition is severe, with diarrhea or 
alternating diarrhea and constipation, with more or less constant 
abdominal distress. A 10-percent evaluation is assigned if the 
condition is moderate, with frequent episodes of bowel disturbance with 
abdominal distress. A zero-percent evaluation is assigned if the 
condition is mild, with ``disturbances of bowel function with 
occasional episodes of abdominal distress.'' Our consultants suggested 
evaluation levels of 30 and 10 percent, with essentially the same 
criteria as the current ones, except for adding ``refractory to medical 
treatment'' to the criteria for 30 percent, and ``partially responsive 
to treatment'' to the criteria for 10 percent. We are proposing to 
remove the subjective terms ``severe,'' ``frequent,'' ``occasional,'' 
etc., from the criteria and to base evaluation on more objective 
criteria, in order to decrease the reliance on ambiguous descriptive 
terms. We propose a 30-percent evaluation for daily or near-daily 
disturbances of bowel function (diarrhea, or alternating diarrhea and 
constipation), bloating, and abdominal cramping or pain, refractory to 
medical treatment, and a 10-percent evaluation for disturbances of 
bowel function (diarrhea, or alternating diarrhea and constipation), 
bloating, and abdominal cramping or pain that occur three or more times 
a month and that respond partially to medical treatment. We propose to 
remove the zero-percent level as unnecessary (see Sec.  4.31). These 
proposed criteria would ensure consistency of evaluations and still be 
in keeping with our consultants' recommendations.

Amebiasis and Bacillary Dysentery

    In the current rating schedule, diagnostic code 7321 is amebiasis, 
and diagnostic code 7322 is bacillary dysentery. Both conditions are 
uncommon today except as acute short-term illnesses. They ordinarily 
resolve without residuals because they are highly responsive to modern 
drug treatment. In accordance with our consultants' suggestion, we 
therefore propose to delete diagnostic code 7321 and diagnostic code 
7322 as unnecessary.

Ulcerative Colitis (Diagnostic Code 7323)

    Ulcerative colitis (diagnostic code 7323) is currently evaluated at 
100, 60 30, or 10 percent. A 100-percent evaluation is assigned if the 
condition is pronounced, resulting in marked malnutrition, anemia, and 
general debility, or if there are serious complications, such as liver 
abscess. A 60-percent evaluation is assigned if the condition is 
severe, with numerous attacks a year and malnutrition, with the health 
only fair during remissions. A 30-percent evaluation is assigned if the 
condition is moderately severe, with frequent exacerbations; and a 10-
percent evaluation is assigned if the condition is moderate, with 
infrequent exacerbations.
    The most common symptoms of ulcerative colitis are abdominal pain 
and bloody diarrhea, but there may also be rectal pain, fever, 
tachycardia, anorexia, malaise, weakness, and other symptoms. In severe 
cases, there may be weight loss, malnutrition, anemia, and 
hypoalbuminemia. Common complications include perforation, stricture, 
hemorrhage, dehydration, fulminant (sudden and intense) colitis, and 
toxic megacolon (a severe distention of the colon that can be life 
threatening). Among other possible complications are liver disease, 
skin nodules, eye problems, colon cancer, and arthritis (Merck, 155-156 
and https://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm#symptoms, National Digestive Diseases Information 
Clearinghouse, February 2006).
    Our consultants suggested we continue evaluations based on 
frequency of episodes, attacks, and exacerbations, and they provided 
some timeframes for their frequency and duration. We propose to use 
their suggestions, in a modified form, removing the subjective language 
such as ``severe'' and ``marked'' that they included. We also further 
propose to specify the usual symptoms of ulcerative colitis in the 
criteria, with bloody diarrhea being the major symptom, and to include 
criteria based on the need for hospitalization for complications or 
continuous treatment with prescription medication. We propose a 100-
percent evaluation for either of the following: malnutrition, 
substantial weight loss, anemia, and general debility with multiple 
attacks of colitis per year, with bloody diarrhea, abdominal or rectal 
pain, fever, and malaise; or hospitalization three or more times per 
year for complications such as hemorrhage, dehydration, obstruction, 
fulminant (sudden and intense) colitis, toxic megacolon, or 
perforation.
    We propose a 60-percent evaluation for either of the following: 
substantial weight loss and anemia, with multiple attacks of colitis 
per year, with bloody diarrhea, abdominal or rectal pain, fever, and 
malaise; or hospitalization two times per year for complications such 
as hemorrhage, dehydration, obstruction, fulminant colitis, toxic 
megacolon, or perforation. We propose a 30-percent evaluation for 
either of the following: three or more attacks of colitis (each lasting 
5 or more days) per year, with diarrhea with blood, pus, or mucous, and 
abdominal or rectal pain; or hospitalization one time per year for

[[Page 39168]]

complications such as hemorrhage, dehydration, obstruction, fulminant 
colitis, toxic megacolon, or perforation. We propose a 10-percent 
evaluation for either of the following: One or two attacks of colitis 
(each lasting 5 or more days) per year with diarrhea with blood, pus, 
or mucous, and abdominal or rectal pain; or continuous treatment with 
prescription medication either to control symptoms or to maintain 
remission.
    We also propose to add a note directing raters to evaluate other 
complications, such as uveitis, ankylosing spondylitis, sclerosing 
cholangitis, etc., separately under an appropriate diagnostic code. We 
propose to add a second note directing raters, if there has been a 
colon resection, to evaluate under diagnostic codes 7350 (colostomy or 
ileostomy) and 7329 (resection of large intestine), as applicable, and 
to combine the evaluations under the provisions of Sec.  4.25, as long 
as the same findings are not used to support more than one evaluation.

Intestinal Parasitic Infections (Diagnostic Code 7324)

    We propose to change the title of diagnostic code 7324 from 
``distomiasis, intestinal or hepatic'' to ``parasitic infections of the 
intestinal tract'' because our consultants advised us that distomiasis 
(formerly used to refer to trematodes or flukes) is a term that is no 
longer used. The generic term ``parasitic infections'' includes all 
types of parasitic infections, not just trematodes or flukes. Parasitic 
infections that do not primarily affect the digestive tract are 
evaluated in the portion of the rating schedule that addresses 
Infectious Diseases, Immune Disorders and Nutritional Deficiencies. The 
current evaluation criteria, with levels of 30, 10, and zero percent, 
are based on whether there are ``severe,'' ``moderate,'' or ``mild'' 
symptoms, with no specific guidance as to the type of symptoms.
    Our consultants suggested criteria of ``severe symptoms including 
diarrhea, abdominal distress, and weight loss, refractory to medical 
treatment'' for a 30-percent evaluation and ``moderate symptoms'' for a 
10-percent evaluation. While more specific than the current criteria, 
they retain subjective language. We propose to remove the subjective 
terms and base evaluation on the presence of diarrhea (which commonly 
means more than three loose watery stools in one day (https://digestive.niddk.nih.gov/ddiseases/pubs/diarrhea/, National Digestive 
Diseases Information Clearinghouse, October 2003)), abdominal pain, and 
weight loss, and on whether continuous treatment with prescription 
medication is required. We propose to delete the zero-percent level, 
since a parasitic infection that does not meet the criteria for a ten-
percent evaluation would be assigned a non-compensable evaluation, and 
this is sufficiently clear without the need for a zero-percent 
evaluation level (see Sec.  4.31).
    We propose to evaluate parasitic infections of the intestinal tract 
at 30 percent if there is daily diarrhea (occurring more than three 
times per day) and abdominal pain, with at least minor weight loss. We 
propose to evaluate them at 10 percent if diarrhea and abdominal pain 
occur, and they require continuous treatment with prescription 
medication for control. In addition, since parasitic infection of the 
gastrointestinal tract may result in a malabsorption syndrome, we 
propose to add a note directing raters to evaluate under proposed 
diagnostic code 7353 (malabsorption syndrome), if malabsorption is 
present, and doing so would result in a higher evaluation.

Chronic Diarrhea of Unknown Etiology (Diagnostic Code 7325)

    Diagnostic code 7325 is currently titled ``Enteritis, chronic'' and 
directs that the condition be rated as irritable colon syndrome 
(diagnostic code 7319). At the suggestion of our consultants, we 
propose to revise the title to ``chronic diarrhea of unknown etiology'' 
because chronic enteritis is no longer considered a specific diagnostic 
entity. We also propose to provide evaluation criteria specific to this 
condition, in accordance with