Schedule for Rating Disabilities: The Digestive System, 19735-19754 [2024-05138]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 89, Number 55 (Wednesday, March 20, 2024)]
[Rules and Regulations]
[Pages 19735-19754]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-05138]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AQ90


Schedule for Rating Disabilities: The Digestive System

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends the Department of Veterans Affairs (VA) 
Schedule for Rating Disabilities (VASRD) by revising the portion of the 
schedule that addresses the Digestive System. The effect of this action 
is to ensure that the rating schedule uses current medical terminology 
and provides detailed and updated criteria for evaluation of digestive 
conditions for disability rating purposes.

DATES: This final rule is effective May 19, 2024.

FOR FURTHER INFORMATION CONTACT: Ulia Sokol, M.D., M.B.A., Medical 
Officer, Regulations Staff, (218A), Compensation Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Avenue NW, Washington, DC 20420, [email protected], (202) 461-
9700. (This is not a toll-free telephone number.)

SUPPLEMENTARY INFORMATION: On January 11, 2022, VA published in the 
Federal Register the proposed rule for Schedule of Rating Disabilities: 
The Digestive System. See 87 FR 1522. VA received 22 comments during 
the 60-day comment period, including from two Veterans Service 
Organizations (Paralyzed Veterans of America and The National Veterans 
Legal Services Program) and two Veterans advocacy groups (The National 
Organization of Veterans' Advocates, Inc. and The National Law School 
Veterans Clinic Consortium). VA appreciates the comments submitted in 
response to the proposed rule. Based on the rationale stated in the 
proposed rule and in this document, the proposed rule is adopted as a 
final rule with minor changes noted below.
    Severability: The provisions of the proposed rule are separate and 
severable from one another, and if any provision is stayed or 
determined to be invalid, the agency would intend that the remaining 
provisions continue in effect. VA has carefully considered the 
requirements of the proposed rule, both individually and in their 
totality, including their potential costs to the agency and benefit to 
veterans. In the event a court were to stay or invalidate one or more 
provisions of this rule as finalized, VA would want the remaining 
portions of the rule as finalized to remain in full force and legal 
effect.

I. Comments of General Support

    One commenter expressed support for utilizing ``undernutrition'' 
instead of ``malnutrition'' under 38 CFR 4.112. VA thanks this 
commenter for their input.
    Another commenter expressed support for the proposed rule because 
it provides more comprehensive evaluative criteria for those with 
assisted nutrition devices such as gastrostomy tubes, total parenteral 
nutrition (TPN) ports, and gastric stimulators. VA thanks this 
commenter for their support.
    One commenter expressed support for the change to DC 7326 for 
Crohn's disease because it comprehensively addresses the symptoms of 
this disease, its treatment modalities, and functional impairment 
caused by this disease. VA thanks this commenter for their support.
    While most commenters generally welcomed modernizing the rating 
schedule and recognized this effort as a thoroughly-researched 
undertaking, some commenters shared some concerns with VA. These 
concerns are addressed in the sections below.

II. Comments Regarding Coexisting Abdominal Conditions Under Sec.  
4.114, Schedule of Ratings--Digestive System

    Two commenters expressed concern regarding the prohibition of 
rating coexisting abdominal conditions under 38 CFR 4.113 and 4.114, 
stating they are too broad in scope. One commenter recommended VA 
should simply have rating specialists consider the anti-pyramiding 
principles set out in 38 CFR 4.14. The other commenter suggested that 
VA specifically reconsider adding the following diagnostic codes to the 
list of codes that cannot be combined with each other: DC 7303, chronic 
complications of upper gastrointestinal surgery, DC 7350, liver 
abscess, DC 7352, pancreas transplant, DC 7355, celiac disease, DC 
7356, gastrointestinal dysmotility syndrome, and DC 7357, post 
pancreatectomy. It was the commenter's opinion that this approach is 
restrictive and precludes the ability to maximize benefits for 
veterans.

[[Page 19736]]

    VA makes no changes based on these comments. First, the addition of 
the newly created diagnostic codes is appropriate due to 38 CFR 4.14 
and 4.113, which advises rating personnel to avoid providing multiple 
evaluations for the same disability under various diagnoses. Even 
though VA is adding diagnostic codes for new conditions, the symptoms 
and functional impairment experienced by these new conditions are 
commonly shared with other diagnoses found in this body system and 
therefore cannot be combined. Next, while 38 CFR 4.114 adheres to the 
provisions laid out in 38 CFR 4.14, it provides a benefit that 38 CFR 
4.14 does not--it allows rating personnel to elevate the evaluation to 
the next higher level when warranted based on the overall disability 
severity. This is a benefit to the veteran that is not available 
through the application of 38 CFR 4.14 alone and provides a favorable 
means of accounting for non-overlapping symptoms. For example, consider 
a veteran evaluated at 30% for the predominant disability of Crohn's 
disease (DC 7326) and 30% for diverticulitis (DC 7327) with non-
overlapping symptoms. When applying the symptoms of diverticulitis to 
Crohn's, the resultant evaluation is higher than that of Crohn's alone 
warranting an elevation to the next higher level under DC 7326, which 
is 60%. The regulation in 38 CFR 4.14 does not allow for elevations in 
this way. Therefore, it is more advantageous that the provisions of 38 
CFR 4.114 be applied for these diagnostic codes than 38 CFR 4.14. 
However, VA notes that the terminology used in this paragraph can be 
revised to aid its interpretation and application. The paragraph 
advises rating personnel to not combine diagnostic codes and to assign 
a single evaluation that reflects the predominant disability picture. 
The term ``combine'' in this paragraph refers to combining disabilities 
as defined in 38 CFR 4.25 for the purposes of determining the combined 
disability evaluation, but it can be misinterpreted as stating to not 
provide service connection for multiple conditions under these 
diagnostic codes. To simplify this language and ensure clarity, VA 
revises it to state that ratings under these diagnostic codes will be 
assigned a single evaluation that reflects the predominant disability 
picture and that elevation to the next higher evaluation can be 
provided if warranted based on the severity of the overall disability.

III. Comments Regarding DC 7202 Tongue, Loss of Whole or Part

    One commenter recommended that VA remove the note under DC 7202 to 
review for Special Monthly Compensation (SMC) for tongue, loss of whole 
or part because the evaluative criteria no longer evaluates aphonia. 
Another commenter asked VA to, ``restore criteria under DC 7202 for the 
amount of tongue removed and speech impairment to address . . . 
situations where communication is impaired but not precluded'' as 
necessary for the grant of special monthly compensation for complete 
organic aphonia. Otherwise, the commenter recommended VA refer to 
another body system that adequately addresses speech impairment due to 
loss of tongue.
    First, the VASRD has two diagnostic codes that provide evaluations 
for speech impairment. One of those diagnostic codes, DC 6519 for 
organic aphonia, is the most appropriate catch-all for speech 
impairment issues due to infection, disease, or in the case of loss of 
whole or part of the tongue, injury. Additionally, DC 6519 provides 
objective criteria to adequately evaluate situations where speech is 
impaired but not precluded. Second, the intent of Note 1 is to provide 
general guidance to the rating personnel to capture any additional 
functional impairment that comes with the loss of the tongue, whole or 
partial. However, VA agrees that removing the note about SMC is 
warranted and that the note should more directly guide rating personnel 
to the more appropriate diagnostic code to evaluate speech impairment 
that can arise due to whole or partial loss of the tongue. Therefore, 
VA revises Note 1 of DC 7202 to refer rating personnel to DC 6519 or DC 
6516 when there is evidence of speech impairment. VA thanks these 
commenters for their input.
    The same commenter pointed out that in the preamble of the proposed 
rule for DC 7202, VA failed to demonstrate how medical treatment and 
rehabilitation can restore speech function to varying degrees. VA 
acknowledges that speech rehabilitation methodology and references to 
other body systems were not discussed in the preamble because those are 
outside the scope of this rulemaking. From a disability compensation 
standpoint, VA already has regulations to address evaluations that need 
review if speech function is restored or the condition otherwise 
improves. See 38 CFR 3.344 and 3.327. VA thanks this commenter but 
makes no changes based on this comment.
    One commenter suggested that VA should recognize that both the 
abilities to swallow and to speak are highly relevant and should be 
considered under DC 7202. Additionally, the commenter recommended that 
VA provide a 30% evaluation for marked loss of speech due to loss of 
tongue. While VA agrees that the ability to swallow and to speak may be 
impaired due to the loss of tongue in whole or in part, speech is not a 
function of the digestive body system. Speech impairment has no effect 
on whether one is able to sufficiently consume or digest sustenance. 
Therefore, it is more appropriate for the evaluative criteria of this 
condition to be limited to its effect on food consumption. Thus, VA 
makes no changes based on this comment.
    Finally, the same commenter suggested that VA specify that 
``medical advisors'' under DC 7202 are not limited to physicians but 
may also include physician assistants, nurse practitioners and 
nutritionists. While VA agrees that physicians are not the only medical 
providers who may provide care, the term ``medical provider'' is used 
throughout the VASRD to encompass a variety of healthcare professionals 
who provide health care services, to include medical care or treatment. 
This is consistent with the use of the term ``medical providers'' 
outside of VA as well. Therefore, VA makes no changes based on this 
comment.

IV. Comments Regarding DC 7203 Esophagus, Stricture of

    One commenter noted that VA use ``dilation'' and ``dilatation'' in 
the evaluation criteria and asked if the terms should be used 
interchangeably. VA recognized that there was a typographical error and 
all instances of the word should have been ``dilatation.'' VA makes a 
clarifying change that amends the proposed text by replacing the word 
``dilation'' with ``dilatation'' at the 50% level, and in Note 5 of DC 
7203.
    The same commenter asked VA to clarify if surgical correction only 
refers to procedures to correct esophageal strictures or if it also 
includes surgeries that relieve gastroesophageal reflux disease (GERD) 
such as Nissen fundoplication. VA clarifies that surgical correction 
only warrants the 80% evaluation when it is used to treat esophageal 
stricture(s). We make no change to DC 7203 based on this comment, but 
make a clarifying change to similar language in DC 7206 as discussed 
under Section XVIII, Technical Corrections, in this document.
    Another commenter noted that the definition of refractory requires 
at least five dilatation treatments at two-week

[[Page 19737]]

intervals and that the 50% criteria is warranted when dilatation occurs 
three or more times per year; however, refractory esophageal strictures 
can receive 30% evaluations, which are warranted when dilatation occurs 
no more than two times per year. The commenter questioned how 
refractory esophageal stricture could warrant a 30% evaluation if, by 
definition, it requires five dilatations per year. VA agrees and 
revises the 30% criteria to only include recurrent esophageal 
strictures while the 50% criteria will reference both recurrent and 
refractory esophageal strictures. VA appreciates the input of these 
commenters.

V. Comments Regarding DC 7206 Gastroesophageal Reflux Disease

    One commenter questioned why there was no mention of the GERD 
evaluative criteria in the Economic Regulatory Impact Analysis (ERIA). 
The discussion regarding how GERD is evaluated was described in the 
preamble of the proposed rule. The ERIA is a systemic approach to 
assessing the positive and negative budgetary effects of proposed and 
existing regulation and non-regulatory alternatives. Budgetary 
documentation does not require information regarding how a condition is 
evaluated because that is not considered pertinent to cost analysis. In 
the ERIA, VA compares the current evaluation levels for DC 7346 with 
the proposed evaluation levels for new DC 7206. For budgetary 
discussions, this is an appropriate methodology to estimate impact of 
proposed changes.
    The same commenter questioned why VA categorized GERD as having a 
``minor budgetary impact'' in the ERIA. As stated in the ERIA, the term 
``minor budgetary impact'' is defined as having costs less than $100 
million over ten years. GERD as a standalone item is anticipated to 
have a minor budgetary impact under that definition, whereas the 
digestive rule overall is anticipated to have a major budgetary impact 
(i.e., greater than $100 million over 10 years).
    Four commenters recommended that VA discontinue rating GERD by 
analogy or reference. In its proposed rule, VA introduced a new 
diagnostic code, DC 7206, with instructions to rate this condition 
under DC 7203. VA agrees that DC 7206 warrants its own rating criteria 
to provide clarity in its application. However, as indicated in the 
proposed rule, VA proposes to evaluate GERD using rating criteria that 
are based on predominant picture of disability due to GERD. These 
criteria consider symptoms of esophageal obstruction and irritation 
that lead to the esophageal stricture, which are consistent with the 
symptoms of GERD and clearly identified under DC 7203, Esophagus, 
stricture of. D. Armstrong et al., ``Canadian consensus conference on 
the management of gastroesophageal reflux disease in adults: Update 
2004,'' 19(1) Canadian J. of Gastroenterology, 15-35 (Jan. 2005). 
Therefore, VA amends the proposed rule by placing the text of the 
evaluation criteria for DC 7206 following its title. DC 7206 will not 
be rated by reference to DC 7203. VA thanks the commenters for their 
suggestions and has updated this DC to reflect this change.
    Six commenters expressed concern that the evaluative criteria for 
DC 7206 do not include symptoms of heartburn, regurgitation, sore 
throat, nausea, chest pain, difficulty swallowing, laryngitis, chronic 
cough, new or worsening asthma, inflammation of the gums, cavities, bad 
breath, disrupted sleep, ulceration, erosion or Barrett's esophagus. 
Three of those six commenters proposed that VA continue to evaluate 
GERD under the current rating schedule, analogous to DC 7346 for hiatal 
hernia.
    Even though these symptoms are important in the diagnosis and 
treatment of GERD, the VA rating schedule bases its evaluations on the 
permanent impairment due to this condition. Such permanent impairment 
of function is based on the scarring due to the chronic irritation of 
the esophagus by acid reflux and consequent development of scar tissue 
that causes esophageal stricture. See Desai JP, Moustarah F., 
Esophageal Stricture [Updated 2021 May 27], https://www.ncbi.nlm.nih.gov/books/NBK542209/. Therefore, for VA disability 
compensation purposes, the functional impairment due to GERD will be 
evaluated and based on the degree of esophageal stricture. VA makes no 
changes based on these comments.
    Two commenters expressed concern that VA has not considered the 
functional impairment posed by GERD. VA disagrees. The VASRD provides 
evaluative criteria in line with 38 U.S.C. 1155 (the statute that 
governs implementation of the ratings schedule) for the evaluation 
based on the average impairments of earning capacity resulting from 
comparable injuries in civilian occupations. Accordingly, VA has 
incorporated considerations regarding the functional impairment caused 
by each disability evaluation in its rating criteria. Therefore, VA 
makes no changes based on these comments.
    Three commenters expressed concern that while esophageal stricture 
is commonly caused by GERD, not all GERD cases result in esophageal 
stricture. While this is true, esophageal stricture is more often than 
not the result of under-treated, late-stage, or refractory GERD. As 
stated above, the purpose of the VASRD is to evaluate the permanent 
residuals of a disability pursuant to 38 U.S.C. 1155. VA makes no 
changes based on these comments.
    Two commenters expressed concern that by changing the VASRD for 
digestive disabilities, including GERD, VA is attempting to save money 
and create a higher burden to obtain compensable evaluations. VA 
disagrees. As stated in the preamble of the proposed rule, the purpose 
of this rule was to reflect medical and scientific advances in the 
understanding and treatment of digestive disorders. 87 FR 1522 (Jan. 
11, 2022). For example, GERD is more appropriately evaluated as 
esophageal stricture than hiatal hernia based on objective findings. 
Id. at 1525 (citing D. Armstrong et al., ``Canadian consensus 
conference on the management of gastroesophageal reflux disease in 
adults: Update 2004,'' 19(1) Canadian J. of Gastroenterology, 15-35 
(Jan. 2005)). This adjustment from evaluating GERD based on subjective 
symptoms to objective measurements is consistent with the stated 
purpose of this rule. Therefore, VA makes no changes based on these 
comments.
    One commenter was concerned because the 2004 study cited in the 
proposed rule stated its objective was to ``develop up-to-date 
evidence-based recommendations relevant to the needs of Canadian health 
care providers for the management of the esophageal manifestations of 
GERD,'' and the study's author noted that ``GERD significantly impairs 
quality of life, both in patients with erosive esophagitis and in those 
who have no endoscopic evidence of injury[.]''
    As stated above, functional impairment is the basis for formulating 
VASRD evaluative criteria. However, ``quality of life'' is not a 
quantifiable measurement for VA disability purposes as VA measures 
functional impairment pursuant to 38 U.S.C. 1155. It is the intent of 
this rule to incorporate modernized terminology and accepted clinical 
treatment into the VASRD. VA recognizes the importance of the symptoms 
that were mentioned by the commenter (e.g., erosions, ulcerations and 
Barrett's esophagus) in the diagnosis and treatment of GERD; however, 
the VASRD concentrates on the ongoing impairment due to this condition. 
Ongoing impairment of function due to GERD is based on the scarring due 
to the chronic irritation of the esophagus by acid reflux and 
consequent development of scar tissue

[[Page 19738]]

that causes esophageal stricture. Therefore, for VA disability 
compensation purposes, the functional impairment due to GERD will be 
evaluated and based on the degree of esophageal stricture. Thus, VA 
makes no changes based on this comment.
    One commenter suggested that acid reflux more than three times a 
week should warrant a 20% evaluation. VA disagrees. Acid reflux is 
already considered in the 10% evaluation, but VA sought a more 
objective measure--specifically, the prescription of medication on a 
daily basis--rather than assessing frequency of acid reflux events. And 
VA compensates such medication usage at the 10% level consistent with 
other conditions that require daily medication for control (e.g., 
cardiac conditions rated under 38 CFR 4.104). VA thanks the commenter 
for their suggestion but makes no changes to the rule.

VI. Comments Regarding DC 7319 Irritable Bowel Syndrome (IBS)

    One commenter asked whether an individual could submit a claim for 
DC 7207 Barrett's esophagus and DC 7319 irritable bowel syndrome (IBS) 
or DC 7326 Crohn's disease. Neither 38 CFR 4.113 nor 38 CFR 4.114 
prohibit separate evaluations of any 7200 series conditions and 7300 
series conditions. Thus, Barrett's esophagus and either IBS or Crohn's 
disease may be separately evaluated without pyramiding if there are no 
similar comorbid symptoms. The same commenter asked a question 
regarding submitting a personal benefit application for these 
conditions. VA always encourages veterans to file claims for benefits 
to which they believe they are entitled and to seek assistance with 
filing claims from accredited representatives whenever necessary. 
However, VA does not respond to comments regarding individual claims in 
rulemakings. VA thanks the commenter and makes no changes based on this 
comment.
    One commenter expressed concern that the terms ``change in stool 
frequency'' and ``change in stool form'' used under DC 7319 are 
ambiguous and highly subjective and could cause confusion and 
disagreements as to the timeframe such change occurred. The commenter 
further stated that while it generally supports VA implementing more 
objective rating criteria based on the Rome IV criteria, the proposed 
changes ``should not mirror this undefined language in the Rome IV 
criteria.'' Instead, the commenter suggested explicitly stating in the 
evaluative criteria that these changes occurred after the onset of IBS.
    VA reserves some of the more detailed instructions, such as the 
definition of ``change'' as it relates to stools for IBS, for its 
subregulatory guidance. Generally, the VASRD does not provide 
definitions of common clinical guidelines. Rather, VA relies on the 
medical community to adhere to current medical practice and standards, 
or otherwise provides the definition of medical terms in subregulatory 
guidance. In this instance, VA will accept the recorded findings of a 
qualified medical provider using the Bristol Stool Scale, also known as 
Meyers Scale, to indicate whether stool frequency and form has changed. 
VA will identify these findings in the training for use of the 
appropriate disability benefits questionnaires (DBQs). Therefore, VA 
makes no changes based on this comment.
    One commenter stated that limiting the evaluation of IBS under DC 
7319 to a maximum schedular evaluation of 30% does not contemplate the 
functional impairment posed by those experiencing severe and frequent 
symptoms. The commenter suggested that DC 7319 instead provide a 50% 
evaluation, comparable to migraine headaches under DC 8100, to account 
for severe economic inadaptability. For evaluative purposes, severe 
economic inadaptability denotes a degree of substantial work impairment 
but does not preclude substantially gainful employment.
    Since the 1960s, VA has moved away from including work-specific 
criterion and instead focused solely on the functional impact caused by 
the condition in its evaluative criteria. The establishment of a 
maximum 30% schedular evaluation reflects VA's judgement as to the 
average occupational impairment resulting from IBS. In exceptional 
cases where IBS has an unusually severe impact on earning capacity, VA 
may consider extraschedular ratings under 38 CFR 3.321 and 4.16.
    Additionally, in its proposed rule, VA did not propose to change 
the number of disability levels for the assessment of functional 
impairment due to IBS. VA kept the same 30%, 10%, and 0% evaluation 
levels, but updated them with more objective criteria derived from the 
Rome IV criteria for IBS. See 87 FR 1522, 1530 (Jan. 11, 2022) (citing 
Brian Lacy, ``Bowel Disorders,'' Gastroenterology, 150: 1393-1407 
(2016)). VA thanks the commenter for the suggestion but makes no change 
based on this comment.
    Finally, the same commenter suggested that VA include a reference 
to DC 7332 for impairment of sphincter control of the rectum and anus 
for veterans who experience incontinence due to IBS. VA does not 
routinely create notes for all possible comorbid manifestations of a 
disease process and declines to do so in this circumstance. The 
regulation in 38 CFR 4.2 advises rating specialists to interpret 
medical evidence so that the appropriate disability is evaluated. VA 
thanks the commenter for this suggestion, but makes no changes based on 
this comment.

VII. Comments Regarding DC 7326 Crohn's Disease or Undifferentiated 
Form of Inflammatory Bowel Disease

    One commenter expressed support for the change to DC 7326 for 
Crohn's disease because it comprehensively addresses the symptoms of 
this disease, all treatment modalities and functional impairment caused 
by this disease. VA thanks this commenter for their support.
    One commenter shared their personal experience with Crohn's disease 
treatment and management. Additionally, the commenter expressed concern 
about medical coverage for veterans and the burden of co-payments for 
medical treatment. VA appreciates this comment, but medical care 
benefit issues are outside of the scope of this rulemaking. Therefore, 
VA makes no changes based on this comment.
    The same commenter noted that mental disorders are frequently 
diagnosed subsequent to Crohn's disease and should be addressed 
accordingly. Currently, VA has the authority to grant entitlement to 
service connection on a secondary basis for disabilities that are 
proximately due to, or aggravated by, service-connected disease or 
injury pursuant to 38 CFR 3.310. This would allow VA to service connect 
a mental disorder due to Crohn's disease without any additional 
revisions to the portion of the rating schedule which addressed 
digestive disabilities. Therefore, VA makes no changes based on this 
comment.
    The same commenter suggested using a 100-point system developed by 
Crohn's and Colitis Foundation of America. However, this point system 
was developed for diagnosis, treatment and management of these diseases 
in a clinical setting and is not appropriate to be used for disability 
evaluation. Therefore, VA makes no changes based on this comment.
    Finally, the same commenter expressed support for the rule change 
for DC 7326 Crohn's disease because it more accurately defines the 
functional impairment in its rating criteria. VA thanks the commenter 
for their support.

[[Page 19739]]

VIII. Comments Regarding DC 7329, Intestine, Large, Resection of

    One commenter suggested that the 100% evaluation criteria for DC 
7329 Intestine, large, resection of, should simply consist of the 
elements from the 60% criteria with one additional element (high-output 
syndrome) instead of three additional elements. The commenter's concern 
was that veterans could experience inconsistent ratings if they fall 
between these two requirements, such as a total colectomy with high-
output syndrome but no ileostomy. Additionally, the commenter suggested 
adding an intermediary 80% evaluation under this DC to cover the cases 
that fall between these two requirements.
    The proposed 100% evaluation criteria include three major elements, 
(1) total colectomy with (2) formation of ileostomy and (3) high-output 
syndrome with more than two episodes of dehydration in the past 12 
months. The episodes of dehydration that require intravenous hydration 
are reflective of the gravity of the consequences of the large 
intestine resection, demonstrating total impairment. The functional 
impairment due to total colectomy with high-output syndrome and total 
colectomy without high-output syndrome has clear demarcation along the 
absence or presence of said high-output syndrome. Therefore, VA 
proposed clearly identifiable levels of disability for the 60% and 100% 
evaluation based on that principle. Furthermore, 38 CFR 4.7 already 
provides guidance to rating specialists to assign the next higher 
evaluation should the disability picture more closely approximate that 
level of disability. VA thanks the commenter for their suggestions but 
declines to make changes based on this comment.
    However, during its internal review, VA noted a minor inconsistency 
in using certain terminology for surgical outcomes for a 40% evaluation 
for a partial colectomy with permanent colostomy and for a 60% 
evaluation for total colectomy without high-output syndrome. VA 
corrects this inconsistent use of medical terminology by revising the 
40% evaluative criteria to read as ``Partial colectomy with permanent 
colostomy or ileostomy without high-output syndrome'' and 60% 
evaluative criteria to read as ``Total colectomy with or without 
permanent colostomy or ileostomy without high-output syndrome.'' This 
clerical change brings additional clarity to the rating criteria for 
the 20%, 40%, 60% and 100% ratings, and assures their consistent 
application by rating specialists. This revision does not result in any 
substantive changes to the criteria under DC 7329.

IX. Comments Regarding DC 7332, Rectum and Anus, Impairment of 
Sphincter Control

    One commenter requested clarification between the terminology 
``wearing'' and ``changing'' of pads under DC 7332, rectum and anus, 
impairment of sphincter control. VA's proposed rating criteria provided 
descriptive criteria that track the Cleveland Clinic Incontinence Scale 
(CCIS), a standardized, evidence-based measure that accounts for 
difficulties with retention and expulsion of stool. This scale 
determines the severity of sphincter impairment, the frequency of 
incontinence, and the extent to which it alters a person's life. See 
A.M. Kaiser, ``The McGraw-Hill Manual of Colorectal Surgery,'' 743 
(2009). For the purposes of VA disability compensation, the term 
``changing'' of pads refers to the need to change a pad due to an 
incontinence to gas, incontinence to liquid or incontinence to solid 
and the resulting soiling of the pad. The term ``wearing'' of pads 
refers to a necessary or advisable measure to address the effects of 
incontinence, regardless of the frequency with which soiling occurs.
    One commenter expressed concern regarding the proposed changes to 
DC 7332 because the evaluative criteria list specific findings that may 
be applied more rigidly than the existing criteria. The same commenter 
proposed VA instead create a non-exclusive example to demonstrate 
levels of loss of control without applying specific findings. As 
compared to the existing rating criteria, the proposed rule contains 
successive criteria, which offer clear and objective findings at each 
level of impairment in line with the CCIS. Additionally, the proposed 
criteria replace subjective terminology such as ``extensive,'' 
``frequent,'' ``occasional,'' and ``slight'' with measurable 
descriptive findings that clarify existing rating criteria. 
Furthermore, each level of disability allows for evaluation based on 
responsiveness to treatment or frequency of incontinence with use of 
pads, which allows flexibility in applying disability evaluation. VA 
thanks the commenter for their suggestion but makes no changes to the 
rule based on this comment.
    The same commenter was concerned that the proposed criteria under 
DC 7332 may impose a higher burden than current procedures to award 
entitlement to special monthly compensation (SMC) under 38 CFR 
3.350(e)(2) and 38 U.S.C. 1114(o) for paraplegia. VA disagrees. Aside 
from making the criteria more objective, VA's proposed revision to this 
diagnostic code includes consideration as to whether loss of anal 
sphincter control is responsive to treatment. This is not incompatible 
with SMC for paraplegia. Rather, 38 CFR 3.350(e)(2) states that ``[t]he 
requirement of loss of anal and bladder sphincter control is met even 
though incontinence has been overcome under a strict regimen of 
rehabilitation of bowel and bladder training and other auxiliary 
measures.'' The fact that the evaluative criteria have become more 
objective and include consideration of treatment response does not make 
it more difficult to be awarded SMC due to paraplegia than under 
current requirements. Therefore, VA makes no changes to this rule based 
on this comment.

X. Comments Regarding DC 7336, Hemorrhoids, External or Internal

    One commenter expressed concern that the 0% (noncompensable) 
evaluation for hemorrhoids under DC 7336 was removed without 
explanation and requested VA reinstate this evaluation. Current VASRD 
criteria warrant a 0% evaluation for mild or moderate internal or 
external hemorrhoids. These rating criteria are unquantifiable and 
nonspecific; therefore, VA removed them. However, 38 CFR 4.31 requires 
VA raters to assign a noncompensable evaluation for any diagnostic code 
in the VASRD where one is not present when the requirements for a 
compensable evaluation are not met. Therefore, VA can still assign 0% 
evaluations for hemorrhoids despite the evaluation level being removed.
    Additionally, the commenter was concerned that without a 
noncompensable evaluation under DC 7336 for hemorrhoids, veterans would 
not be eligible for the 10% evaluation awarded for two or more 
noncompensable evaluations under 38 CFR 3.324. As stated above, despite 
the removal of the noncompensable evaluation under DC 7336, veterans 
may be eligible for a 10% rating based on two or more noncompensable 
evaluations under 38 CFR 3.324 even if those noncompensable evaluations 
are awards through 38 CFR 4.31. Therefore, VA makes no changes based on 
this comment.

XI. Comments Regarding DC 7345, Chronic Liver Disease Without Cirrhosis

    One commenter suggested adding a 10% evaluation under DC 7345 for 
chronic liver disease without cirrhosis to account for those in 
remission who

[[Page 19740]]

may experience spontaneous reactivation of hepatitis B and/or 
experience mental health symptoms related to the anxiety that 
spontaneous reactivation could occur. Proposed DC 7345 provides a 0% 
evaluation for those with a history of liver disease who are 
asymptomatic. Compensable evaluations, 10% or more, are based on 
laboratory findings and/or symptoms associated with a disease. Should 
the disease recur, the veteran may submit a claim for increase based on 
recurrence and level of severity. Regarding mental symptoms associated 
with chronic liver disease, VA may grant entitlement to service 
connection on a secondary basis for disabilities that are proximately 
due to, or aggravated by, service-connected disease or injury pursuant 
to 38 CFR 3.310. VA thanks this commenter, but makes no changes based 
on this comment.

XII. Comments Regarding DC 7347, Pancreatitis, Chronic

    One commenter was concerned that the enteral feeding element of the 
rating criteria is not included in every evaluation level under DC 
7347, Pancreatitis, chronic. Additionally, the commenter asked for 
further clarification on how to rate this condition if it requires 
enteral feeding, regardless of whether or not the feeding causes 
complication. The commenter also stated that other proposed criteria, 
specifically DCs 7301, 7303, and 7328, provide an 80% disability rating 
for enteral feeding whereas this code and 7330 only provide 60%. The 
commenter suggested that VA consider applying the 80% rating for 
enteral feeding to align it with the rest of the proposed ratings.
    First, VA closely examined the full range of functional impairment 
due to the chronic pancreatitis during its review of this VASRD body 
system. VA found that the proposed rating criteria is aligned 
appropriately with the functional impairment due to the chronic 
pancreatitis, as described in the preamble of the proposed rule. To 
that end, consideration of enteral feeding is not necessary at every 
evaluation level.
    Second, DCs 7301, 7303, and 7328 provide an 80% disability rating 
for TPN, not enteral feeding. TPN provides nutrition outside of the 
digestive tract (intravenously), whereas enteral feeding provides 
nutrition through the digestive tract by way of a feeding tube. 
Additionally, TPN is primarily indicated when enteral feeding is not 
possible. See Maudar K.K. (1995), TOTAL PARENTERAL NUTRITION, Medical 
journal, Armed Forces India, 51(2), 122-126, https://doi.org/10.1016/S0377-1237(17)30942-5. Thus, TPN is assigned a higher evaluation than 
enteral feeding based on the need for intravenous nutrition due to the 
greater impairment of functioning of the digestive tract. Therefore, VA 
makes no changes based on this comment.

XIII. Comments Regarding DC 7355, Celiac Disease

    One commenter suggested using ``undernutrition'' instead of 
``malabsorption syndrome'' under DC 7355 for celiac disease because 
malabsorption is not defined in the VASRD, and it ultimately results in 
undernutrition. VA disagrees. Malabsorption syndrome is separate from 
undernutrition condition; these two conditions cannot be used 
interchangeably. Furthermore, malabsorption syndrome has its own clear 
clinical definition and does not have to be defined in the VASRD. 
Therefore, VA makes no changes based on this comment.

XIV. Comments Regarding Dysphagia

    One commenter asked whether the term dysphagia is defined in this 
rule as difficulty swallowing or a condition encompassing a variety of 
symptoms such as pain while swallowing, a sensation of food getting 
stuck in the throat or chest, drooling, hoarseness, regurgitation, etc. 
As stated above, the VASRD does not provide detailed definitions of 
common clinical guidelines. Qualified clinicians may determine the 
presence or absence of any symptoms of GERD upon examination, including 
the common symptom of dysphasia, which may manifest as a variety of 
symptoms including difficulty of swallowing. VA thanks the commenter 
but makes no changes to the rule based on this comment.

XV. Comments Regarding General Terminology

    One commenter expressed concern regarding with the inconsistency of 
using general terminology, such as ``prescribed dietary modification,'' 
``dietary intervention,'' and ``dietary restriction'' under a number of 
diagnostic codes. VA uses all three references--prescribed dietary 
modification, dietary intervention, and dietary restriction--to 
describe different types of therapeutic diets. A therapeutic diet is a 
meal plan that controls the intake of certain foods or nutrients and is 
part of the treatment of a medical condition and is normally prescribed 
by a physician and planned by a dietician. A therapeutic diet is 
usually a modification of a regular diet, and it is modified or 
tailored to fit the nutrition needs of a particular person. VA uses 
these references as appropriate under specific diagnostic codes 
according to specific clinical situations. Additionally, in issuing its 
proposed rule, VA provided specific examples of prescribed dietary 
modification (e.g., therapeutic diets can be modified for nutrients or 
texture due to impaired swallowing or frequent aspiration), dietary 
intervention (e.g., a prescribed gluten-free diet), and dietary 
restriction (e.g., a reduction of particular or total nutrient intake 
without causing malnutrition). Therefore, VA makes no changes based on 
this comment.
    The same commenter stated that the 30% criteria for DC 7356, 
Gastrointestinal dysmotility syndrome, is repetitive and misleading 
because it requires both symptoms of intestinal pseudo-obstruction 
(CIPO) and symptoms of intestinal motility disorder, but CIPO is an 
intestinal motility disorder. VA agrees and revises the criteria at the 
30% level to use ``or'' instead of ``; and.'' CIPO is a specific 
diagnosis of an intestinal motility disorder, so use of the conjunctive 
``and'' makes reference to CIPO redundant. VA thanks the commenter for 
their comment.
    Additionally, the commenter questioned whether recurrent emergency 
treatment for the 50% evaluation for DC 7356 only applies to episodes 
of intestinal obstruction or if it also applies to regurgitation. VA 
clarifies once more that the recurrent emergency treatment for the 50% 
evaluation also applies to regurgitation due to poor gastric emptying, 
abdominal pain, recurrent nausea or recurrent vomiting. The commenter 
asked that VA adjust the wording for further clarification. However, VA 
notes that when evaluation criteria use the disjunctive ``or'' without 
a semi-colon, then ``or'' indicates that the qualifier applies to 
criterion on both sides of the ``or.'' That is the case regarding 
recurrent emergency treatment in this evaluation. Conversely, when VA 
uses ``or'' with a semi-colon, then the qualifier only applies to the 
criterion on the same side of the semi-colon. Therefore, a 50% 
evaluation would be warranted if the evidence demonstrated intermittent 
tube feeding for nutritional support, along with recurrent emergency 
treatment for either intestinal obstruction due to poor gastric 
emptying, abdominal pain, recurrent nausea, or recurrent vomiting or 
regurgitation due to poor gastric emptying, abdominal pain, recurrent 
nausea, or recurrent vomiting. VA makes no changes based on these 
comments.

[[Page 19741]]

XVI. Comments of General Disagreement

    One commenter indicated that the current VASRD does not incorporate 
the most up-to-date and accurate scientific data because its rating 
criteria do not allow clinicians to more accurately diagnose and 
therefore to fairly distribute disability services. The VASRD is not 
intended to be utilized in a clinical setting to identify, diagnose or 
treat injuries, diseases or disorders. The VASRD provides evaluative 
criteria based on the average impairments of earning capacity resulting 
from comparable injuries in civilian occupations, in line with VA's 
authority under 38 U.S.C. 1155 to adopt a rating schedule. Clinicians 
are urged to utilize standard diagnostic and treatment practices in 
their respective clinical setting. Therefore, VA makes no changes based 
on this comment.
    Two commenters expressed concern that VA is taking benefits away 
from veterans and disagreed with the rule change in general. The 
commenters did not offer any specific recommendations. The primary 
objective for this rule is to revise the rating criteria to reflect 
updated medical advances, add new medical conditions and update 
terminology. There are no provisions in this rule that seek to remove 
any entitlement to benefits, and this rule would not disturb ratings 
currently in effect. Therefore, VA makes no changes based on these 
comments.

XVII. Comments Beyond the Scope of This Rulemaking

    One commenter shared their experience seeking diagnoses for their 
digestive symptoms due to Gulf War Illness. The regulation in 38 CFR 
3.317(a)(2)(i)(B)(3) creates a presumption of service connection for 
certain Persian Gulf veterans who exhibit functional gastrointestinal 
disorders. The presumption of service connection for those disorders 
falls outside the scope of this rulemaking. Commentary or advice for 
questions regarding individual claims also fall outside of the scope of 
this rulemaking. Therefore, VA makes no changes based on this comment.

XVIII. Technical Corrections

    During its internal review, VA identified a number of minor issues 
that are clerical and typographical in nature and took a corrective 
action in its final rule with minor changes as noted below.
    VA makes a minor typographical correction to revised Sec.  
4.112(d)(2). In the proposed rule, the last sentence of the revised 
regulation used the word ``parental'' when describing the function of 
nasogastric or nasoenteral feeding tubes. VA amends this sentence by 
replacing ``assisted parental nutrition'' with ``assisted parenteral 
nutrition.'' This change to the language does not result in any 
substantive changes to Sec.  4.112(d)(2).
    VA makes minor clerical changes to the paragraph under 38 CFR 
4.114, Schedule of ratings--digestive system. To streamline this 
regulatory language and to ensure its clarity, VA revises 38 CFR 4.114 
to (1) state that ratings under these diagnostic codes will be assigned 
a single evaluation that reflects the predominant disability picture 
and (2) that, if warranted, elevation of the disability rating to the 
next higher evaluation level can be provided and will be based on the 
severity of the overall disability under 38 CFR 4.114. This change to 
the language does not result in any substantive changes to the 
paragraph under 38 CFR 4.114, Schedule of ratings--digestive system.
    VA makes a minor clerical correction to DC 7206, Gastroesophageal 
reflux disease, to the 80% disability level language. To promote 
clarity, VA amends the evaluative criteria for an 80% disability rating 
by adding the words ``of esophageal stricture(s)'' after ``treatment 
with either surgical correction.'' This clerical change is intended to 
specify that the surgical correction applies only to correction of 
esophageal stricture(s) and not any other conditions. This change does 
not result in any substantive changes to the criteria under DC 7206.
    VA makes clerical changes under DC 7303, Chronic complications of 
upper gastrointestinal surgery. The 30% and 50% disability ratings 
discussed ``vomiting not controlled by oral dietary modification'' or 
``vomiting not controlled by medical treatment.'' To promote clarity, 
VA removes the phrase ``not controlled by'' and replaces it with the 
word ``despite.'' This change to the language does not result in any 
substantive changes to the criteria under DC 7303.
    VA makes two clerical changes under DC 7304, Peptic ulcer disease. 
First, the rating criteria under the 0% disability rating mentions an 
x-ray test as one of the diagnostic imaging studies to record a history 
of peptic ulcer disease. VA replaces the reference to just one 
diagnostic imaging study, such as an x-ray test, with a general 
reference to diagnostic imaging studies, such as an X-ray, CT scan, 
MRI, and others. This clerical change brings additional clarity to the 
rating criteria for a 0% evaluation. This change to the language does 
not result in any substantive changes to the criteria under DC 7304.
    Second, VA amends the note under DC 7304 to include the following 
standard instruction: ``Apply the provisions of Sec.  3.105(e) to any 
change in evaluation based upon that or any subsequent examination.'' 
This clerical change is consistent with the reduction of evaluations 
under 38 CFR 3.105(e) and with notes regarding mandatory VA medical 
examinations throughout the VASRD. While VA inadvertently left this 
instruction out of the proposed rule, this addition does not result in 
any substantive changes to the criteria under DC 7304.
    VA makes a clerical change under DC 7312, Cirrhosis of the liver. 
In the proposed rule, one of the criteria for a 100% evaluation is 
listed as encephalopathy, whereas one of the criteria for a 60% 
evaluation is listed as hepatic encephalopathy. To avoid confusion and 
ensure consistency in the application of the rating schedule, VA 
replaces the phrase ``encephalopathy'' in the 100% criteria with 
``hepatic encephalopathy.'' This change to the language does not result 
in any substantive changes to the criteria under DC 7312.
    VA makes a clerical change to the note under DC 7317, Gallbladder, 
injury of. In the proposed rule, VA instructs adjudicators that 
adhesions are not necessary when rating under DC 7301 (Adhesions of the 
peritoneum due to surgery, trauma, disease, or infection). As written, 
this note appears contradictory and could lead to confusion in applying 
the correct evaluation. To clarify the intent of this note, VA makes a 
minor clerical change by stating that when gallbladder injuries are 
rated by analogy under DC 7301, a finding of adhesion is not necessary. 
This change is structural in nature and does not result in any 
substantive changes to the rating criteria.
    VA identified that DC 7319 had one note labeled Note 1. There is 
only one note in relation to DC 7319 and, therefore, no numerical 
designation is required. To provide consistency and clarity, VA 
corrects this typographical error and revises DC 7319 to remove the 
numerical designation.
    VA makes a clerical change under DC 7319, Irritable bowel syndrome 
(IBS) and DC 7326, Crohn's Disease. In the proposed rule, VA listed 
``distension'' under the evaluative criteria for the 20% and 30% 
evaluations levels under DC 7319 and listed ``distention'' under the 
10% evaluation level of DC 7319 and the 100% evaluation level of DC 
7326. To ensure consistency, VA corrects this typographical error and 
changes the

[[Page 19742]]

spelling at the 10% level under DC 7319 and the 100% evaluation under 
DC 7326 to ``distension.''
    VA makes two minor clerical corrections to DC 7330, Intestinal 
fistulous disease, external at the 100% evaluation. VA amends the 
evaluative language by replacing ``enteral nutrition'' with ``enteral 
nutritional support.'' Additionally, VA specifies the size of the 
ostomy bags by adding ``(sized 130cc).'' This language is consistent 
with the 60% evaluative criteria under DC 7330. These changes do not 
result in any substantive changes to the criteria under DC 7330.
    VA makes two minor clerical corrections to DC 7351, Liver 
transplant, at the 30 and 60-percent disability levels. To promote 
clarity, VA amends the evaluative criteria for 30% disability rating by 
adding the words ``Following transplant surgery,'' to the existing 
language ``minimum rating.'' The minimum rating for liver transplant 
surgery was applicable to the veterans with liver transplant. The 
minimum rating's intent was to compensate veterans for post-transplant 
functional impairment due to antirejection therapy and other liver 
transplant medical management treatment modalities. Therefore, this 
change to the language does not result in any substantive changes to 
the criteria under DC 7351.
    VA amends the evaluative criteria for a 60% disability rating by 
replacing the word ``retransplantation'' with the words ``transplant 
surgery,'' which is consistent with medical terminology that is 
currently used to describe both first organ transplant surgery and any 
subsequent organ transplant surgery. Additionally, VA adds the word 
``eligible'' to the language ``awaiting'' to read ``Eligible and 
awaiting transplant surgery, minimum rating.'' This clerical change 
brings additional clarity to VA's intent in revising the rating 
criteria for a 60% disability rating, which is to capture a specific 
population of veterans who are awaiting liver transplant surgery and 
who are eligible candidates for such surgery. This change to the 
language does not result in any substantive changes to the criteria 
under DC 7351.
    VA noted a minor inconsistency in the use of the preposition 
``with'' in the 30%, 50%, and 80% disability levels under DC 7355, 
Celiac disease. At the 30% level, it reads, ``Malabsorption syndrome 
with chronic diarrhea'', whereas at the 50% level it reads, 
``Malabsorption syndrome that causes chronic diarrhea.'' To promote 
clarity and consistency, VA amends the proposed text at the 50% level 
by replacing ``that causes'' with the preposition ``with.'' The 50% 
level now begins with the phrase, ``Malabsorption syndrome with chronic 
diarrhea.'' To ensure standardization at all levels, VA makes a similar 
amendment to the proposed text at the 80% level by replacing ``that 
causes'' with the preposition ``with.'' The 80% level now begins with 
the phrase, ``Malabsorption syndrome with weakness.'' This change to 
the language does not result in any substantive changes to the criteria 
under DC 7355, Celiac disease.
    VA makes five clerical corrections under 38 CFR 4.114 for DCs 7301 
Peritoneum, adhesions of, due to surgery, trauma, disease, or 
infection, 7303 Chronic complications of upper gastrointestinal 
surgery, 7328 Intestine, small, resection of, 7330 Intestinal fistulous 
disease, external, and 7356 Gastrointestinal dysmotility syndrome. For 
consistency and clarity, VA amends the evaluative language for each 
occurrence where a total parenteral nutrition is mentioned. Throughout 
its regulation, VA will refer to total parenteral nutrition as ``total 
parenteral nutrition (TPN).'' These changes do not result in any 
substantive changes to the criteria under DCs 7301, 7303, 7328, 7330, 
and 7356.

Executive Orders 12866, 13563 and 14094

    Executive Order 12866 (Regulatory Planning and Review) directs 
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 14094 (Executive Order on 
Modernizing Regulatory Review) supplements and reaffirms the 
principles, structures, and definitions governing contemporary 
regulatory review established in Executive Order 12866 of September 30, 
1993 (Regulatory Planning and Review), and Executive Order 13563 of 
January 18, 2011 (Improving Regulation and Regulatory Review). The 
Office of Information and Regulatory Affairs has determined that this 
rulemaking is a significant regulatory action under Executive Order 
12866, section 3(f)(1), as amended by Executive Order 14094. The 
Regulatory Impact Analysis associated with this rulemaking can be found 
as a supporting document at www.regulations.gov.

Regulatory Flexibility Act

    The Secretary hereby certifies that this final rule will 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). The factual basis for this certification is based on the fact 
that small entities or businesses are not affected by revisions to the 
VASRD.
    Therefore, pursuant to 5 U.S.C. 605(b), the initial and final 
regulatory flexibility analysis requirements of 5 U.S.C. 603 and 604 do 
not apply.

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 final rule would have no such effect 
on State, local, and tribal governments, or on the private sector.

Paperwork Reduction Act

    This final rule contains no provisions constituting a collection of 
information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).

Congressional Review Act

    Under the Congressional Review Act, this regulatory action may 
result in an annual effect on the economy of $100 million or more, 5 
U.S.C. 804(2), and so is subject to the 60-day delay in effective date 
under 5 U.S.C. 801(a)(3). In accordance with 5 U.S.C. 801(a)(1), VA 
will submit to the Comptroller General and to Congress a copy of this 
regulation and the Regulatory Impact Analysis (RIA) associated with the 
regulation.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved and signed 
this document on March 4, 2024, and authorized the undersigned to sign 
and submit the document to the Office of the Federal Register for 
publication

[[Page 19743]]

electronically as an official document of the Department of Veterans 
Affairs.

Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
General Counsel, Department of Veterans Affairs.

    For the reasons set out in the preamble, VA amends 38 CFR part 4 as 
set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

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

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


Sec.  4.110   [Removed and Reserved]

0
2. Remove and reserve Sec.  4.110.


Sec.  4.111   [Removed and Reserved]

0
3. Remove and reserve Sec.  4.111.

0
4. Revise Sec.  4.112 to read as follows:


Sec.  4.112   Weight loss and nutrition.

    The following terms apply when evaluating conditions in Sec.  
4.114:
    (a) Weight loss. Substantial weight loss means involuntary loss 
greater than 20% of an individual's baseline weight sustained for three 
months with diminished quality of self-care or work tasks. The term 
minor weight loss means involuntary weight loss between 10% and 20% of 
an individual's baseline weight sustained for three months with 
gastrointestinal-related symptoms, involving diminished quality of 
self-care or work tasks, or decreased food intake. The term inability 
to gain weight means substantial weight loss with the inability to 
regain it despite following appropriate therapy.
    (b) Baseline weight. Baseline weight means the clinically 
documented average weight for the two-year period preceding the onset 
of illness or, if relevant, the weight recorded at the veteran's most 
recent discharge physical. If neither of these weights is available or 
currently relevant, then use ideal body weight as determined by either 
the Hamwi formula or Body Mass Index tables, whichever is most 
favorable to the veteran.
    (c) Undernutrition. Undernutrition means a deficiency resulting 
from insufficient intake of one or multiple essential nutrients, or the 
inability of the body to absorb, utilize, or retain such nutrients. 
Undernutrition is characterized by failure of the body to maintain 
normal organ functions and healthy tissues. Signs and symptoms may 
include loss of subcutaneous tissue, edema, peripheral neuropathy, 
muscle wasting, weakness, abdominal distention, ascites, and Body Mass 
Index below normal range.
    (d) Nutritional support. Paragraphs (d)(1) and (2) of this section 
describe various nutritional support methods used to treat certain 
digestive conditions.
    (1) Total parenteral nutrition (TPN) or hyperalimentation is a 
special liquid mixture given into the blood through an intravenous 
catheter. The mixture contains proteins, carbohydrates (sugars), fats, 
vitamins, and minerals. TPN bypasses the normal digestion in the 
stomach and bowel.
    (2) Assisted enteral nutrition requires a special liquid mixture 
(containing proteins, carbohydrates (sugar), fats, vitamins, and 
minerals) to be delivered into the stomach or bowel through a flexible 
feeding tube. Percutaneous endoscopic gastrostomy is a type of assisted 
enteral nutrition in which a flexible feeding tube is inserted through 
the abdominal wall and into the stomach. Nasogastric or nasoenteral 
feeding tube is a type of assisted parenteral nutrition in which a 
flexible feeding tube is inserted through the nose into the stomach or 
bowel.


0
5. Amends Sec.  4.114 by:
0
a. Revising the introductory text and the entries for diagnostic codes 
7200 through 7205;
0
b. Adding in numerical order entries for diagnostic codes 7206 and 
7207;
0
c. Revising the entry for diagnostic code 7301;
0
d. Adding in numerical order an entry for diagnostic code 7303;
0
e. Revising the entry for diagnostic code 7304;
0
f. Removing the entries for diagnostic codes 7305 and 7306;
0
g. Revising the entries for diagnostic codes 7307 through 7310, 7312, 
7314, and 7315;
0
h. Removing the entry for diagnostic code 7316;
0
i. Revising the entries for diagnostic codes 7317 through 7319;
0
j. Removing the entries for diagnostic codes 7321 and 7322;
0
k. Revising the entry for diagnostic code 7323;
0
l. Removing the entry for diagnostic code 7324;
0
m. Revising the entries for diagnostic codes 7325 through 7330 and 7332 
through 7338;
0
n. Removing the entries for diagnostic codes 7339 and 7340;
0
o. Revising the entries for diagnostic codes 7344 through 7348;
0
p. Adding in numerical order an entry for diagnostic code 7350;
0
q. Revising the entry for diagnostic code 7351;
0
r. Adding in numerical order an entry for diagnostic code 7352;
0
s. Revising the entry for diagnostic code 7354; and
0
t. Adding in numerical order entries for diagnostic codes 7355 through 
7357.
    The revisions and additions read as follows:


Sec.  4.114   Schedule of ratings--digestive system.

    Do not combine ratings under diagnostic codes 7301 through 7329 
inclusive, 7331, 7342, 7345 through 7350 inclusive, 7352, and 7355 
through 7357 inclusive, with each other. Instead, when more than one 
rating is warranted under those diagnostic codes, assign a single 
evaluation under the diagnostic code that reflects the predominant 
disability picture, and elevate it to the next higher evaluation if 
warranted by the severity of the overall disability.

------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
7200 Soft tissue injury of the mouth, other than tongue
 or lips:
    Rate as for disfigurement (diagnostic codes 7800 and
     7804) and impairment of mastication.
7201 Lips, injuries of:
    Rate as disfigurement (diagnostic codes 7800 and
     7804).
7202 Tongue, loss of whole or part:
    Absent oral nutritional intake......................             100
    Intact oral nutritional intake with permanently                   60
     impaired swallowing function that requires
     prescribed dietary modification....................
    Intact oral nutritional intake with permanently                   30
     impaired swallowing function without prescribed
     dietary modification...............................
    Note (1): Rate the residuals of speech impairment as
     complete organic aphonia (DC 6519) or incomplete
     aphonia as laryngitis, chronic (DC 6516).
    Note (2): Dietary modifications due to this
     condition must be prescribed by a medical provider.
7203 Esophagus, stricture of:

[[Page 19744]]

 
    Documented history of recurrent or refractory                     80
     esophageal stricture(s) causing dysphagia with at
     least one of the symptoms present: (1) aspiration,
     (2) undernutrition, and/or (3) substantial weight
     loss as defined by Sec.   4.112(a) and treatment
     with either surgical correction or percutaneous
     esophago-gastrointestinal tube (PEG tube)..........
    Documented history of recurrent or refractory                     50
     esophageal stricture(s) causing dysphagia which
     requires at least one of the following (1)
     dilatation 3 or more times per year, (2) dilatation
     using steroids at least one time per year, or (3)
     esophageal stent placement.........................
    Documented history of recurrent esophageal                        30
     stricture(s) causing dysphagia which requires
     dilatation no more than 2 times per year...........
    Documented history of esophageal stricture(s) that                10
     requires daily medications to control dysphagia
     otherwise asymptomatic.............................
    Documented history without daily symptoms or                       0
     requirement for daily medications..................
    Note (1): Findings must be documented by barium
     swallow, computerized tomography, or
     esophagogastroduodenoscopy.
    Note (2): Non-gastrointestinal complications of
     procedures should be rated under the appropriate
     system.
    Note (3): This diagnostic code applies, but is not
     limited to, esophagitis, mechanical or chemical;
     Mallory Weiss syndrome (bleeding at junction of
     esophagus and stomach due to tears) due to caustic
     ingestion of alkali or acid; drug-induced or
     infectious esophagitis due to Candida, virus, or
     other organism; idiopathic eosinophilic, or
     lymphocytic esophagitis; esophagitis due to
     radiation therapy; esophagitis due to peptic
     stricture; and any esophageal condition that
     requires treatment with sclerotherapy.
    Note (4): Recurrent esophageal stricture is defined
     as the inability to maintain target esophageal
     diameter beyond 4 weeks after the target diameter
     has been achieved.
    Note (5): Refractory esophageal stricture is defined
     as the inability to achieve target esophageal
     diameter despite receiving no fewer than 5
     dilatation sessions performed at 2-week intervals.
7204 Esophageal motility disorder:
    Rate as esophagus, stricture of (DC 7203).
    Note: This diagnostic code applies, but is not
     limited to, achalasia (cardiospasm), diffuse
     esophageal spasm (DES), corkscrew esophagus,
     nutcracker esophagus, and other motor disorders of
     the esophagus; esophageal rings (including Schatzki
     rings), mucosal webs or folds, and impairment of
     the esophagus caused by systemic conditions such as
     myasthenia gravis, scleroderma, and other
     neurologic conditions.
7205 Esophagus, diverticulum of, acquired:
    Rate as esophagus, stricture of (DC 7203).
    Note: This diagnostic code, applies, but is not
     limited to, pharyngo- esophageal (Zenker's)
     diverticulum, mid-esophageal diverticulum, and
     epiphrenic (distal esophagus) diverticulum.
7206 Gastroesophageal reflux disease:
    Documented history of recurrent or refractory                     80
     esophageal stricture(s) causing dysphagia with at
     least one of the symptoms present: (1) aspiration,
     (2) undernutrition, and/or (3) substantial weight
     loss as defined by Sec.   4.112(a) and treatment
     with either surgical correction of esophageal
     stricture(s) or percutaneous esophago-
     gastrointestinal tube (PEG tube)...................
    Documented history of recurrent or refractory                     50
     esophageal stricture(s) causing dysphagia which
     requires at least one of the following (1)
     dilatation 3 or more times per year, (2) dilatation
     using steroids at least one time per year, or (3)
     esophageal stent placement.........................
    Documented history of recurrent esophageal                        30
     stricture(s) causing dysphagia which requires
     dilatation no more than 2 times per year...........
    Documented history of esophageal stricture(s) that                10
     requires daily medications to control dysphagia
     otherwise asymptomatic.............................
    Documented history without daily symptoms or                       0
     requirement for daily medications..................
    Note (1): Findings must be documented by barium
     swallow, computerized tomography, or
     esophagogastroduodenoscopy.
    Note (2): Non-gastrointestinal complications of
     procedures should be rated under the appropriate
     system.
    Note (3): This diagnostic code applies, but is not
     limited to, esophagitis, mechanical or chemical;
     Mallory Weiss syndrome (bleeding at junction of
     esophagus and stomach due to tears) due to caustic
     ingestion of alkali or acid; drug-induced or
     infectious esophagitis due to Candida, virus, or
     other organism; idiopathic eosinophilic, or
     lymphocytic esophagitis; esophagitis due to
     radiation therapy; esophagitis due to peptic
     stricture; and any esophageal condition that
     requires treatment with sclerotherapy.
    Note (4): Recurrent esophageal stricture is defined
     as the inability to maintain target esophageal
     diameter beyond 4 weeks after the target diameter
     has been achieved.
    Note (5): Refractory esophageal stricture is defined
     as the inability to achieve target esophageal
     diameter despite receiving no fewer than 5
     dilatation sessions performed at 2-week intervals.
7207 Barrett's esophagus:
    With esophageal stricture: Rate as esophagus,
     stricture of (DC 7203).
    Without esophageal stricture:
    Documented by pathologic diagnosis with high-grade                30
     dysplasia..........................................
    Documented by pathologic diagnosis with low-grade                 10
     dysplasia..........................................
    Note (1): If malignancy develops, rate as malignant
     neoplasms of the digestive system, exclusive of
     skin growths (DC 7343).
    Note (2): If the condition is resolved via surgery,
     radiofrequency ablation, or other treatment, rate
     residuals as esophagus, stricture of (DC 7203).
7301 Peritoneum, adhesions of, due to surgery, trauma,
 disease, or infection:
    Persistent partial bowel obstruction that is either               80
     inoperable and refractory to treatment, or requires
     total parenteral nutrition (TPN) for obstructive
     symptoms...........................................
    Symptomatic peritoneal adhesions, persisting or                   50
     recurring after surgery, trauma, inflammatory
     disease process such as chronic cholecystitis or
     Crohn's disease, or infection, as determined by a
     healthcare provider; and clinical evidence of
     recurrent obstruction requiring hospitalization at
     least once a year; and medically-directed dietary
     modification other than total parenteral nutrition
     (TPN); and at least one of the following: (1)
     abdominal pain, (2) nausea, (3) vomiting, (4)
     colic, (5) constipation, or (6) diarrhea...........
    Symptomatic peritoneal adhesions, persisting or                   30
     recurring after surgery, trauma, inflammatory
     disease process such as chronic cholecystitis or
     Crohn's disease, or infection, as determined by a
     healthcare provider; and medically-directed dietary
     modification other than total parenteral nutrition
     (TPN); and at least one of the following: (1)
     abdominal pain, (2) nausea, (3) vomiting, (4)
     colic, (5) constipation, or (6) diarrhea...........

[[Page 19745]]

 
    Symptomatic peritoneal adhesions, persisting or                   10
     recurring after surgery, trauma, inflammatory
     disease process such as chronic cholecystitis or
     Crohn's disease, or infection, as determined by a
     healthcare provider, and at least one of the
     following: (1) abdominal pain, (2) nausea, (3)
     vomiting, (4) colic, (5) constipation, or (6)
     diarrhea...........................................
    History of peritoneal adhesions, currently                         0
     asymptomatic.......................................
7303 Chronic complications of upper gastrointestinal
 surgery:
    Requiring continuous total parenteral nutrition                   80
     (TPN) or tube feeding for a period longer than 30
     consecutive days in the last six months............
    Any one of the following symptoms with or without                 50
     pain: (1) daily vomiting despite oral dietary
     modification or medication; (2) six or more watery
     bowel movements per day every day, or explosive
     bowel movements that are difficult to predict or
     control; (3) post-prandial (meal-induced) light-
     headedness (syncope) with sweating and the need for
     medications to specifically treat complications of
     upper gastrointestinal surgery such as dumping
     syndrome or delayed gastric emptying...............
    With two or more of the following symptoms: (1)                   30
     vomiting two or more times per week or vomiting
     despite medical treatment; (2) discomfort or pain
     within an hour of eating and requiring ongoing oral
     dietary modification; (3) three to five watery
     bowel movements per day every day..................
    With either nausea or vomiting managed by ongoing                 10
     medical treatment..................................
    Post-operative status, asymptomatic.................               0
    Note (1): For resection of small intestine, use DC
     7328.
    Note (2): If pancreatic surgery results in a vitamin
     or mineral deficiency (e.g., B12, iron, calcium, or
     fat-soluble vitamins), evaluate under the
     appropriate vitamin/mineral deficiency code and
     assign the higher rating. For example, evaluate
     Vitamin A, B, C or D deficiencies under DC 6313;
     ocular manifestations of vitamin deficiencies, such
     as night blindness, under DC 6313; keratitis or
     keratomalacia due to Vitamin A deficiency under DC
     6001; Vitamin E deficiency under neuropathy; and
     Vitamin K deficiency under prolonged clotting
     (e.g., DC 7705).
    Note (3): This diagnostic code includes operations
     performed on the esophagus, stomach, pancreas, and
     small intestine, including bariatric surgery.
7304 Peptic ulcer disease:
    Post-operative for perforation or hemorrhage, for                100
     three months.......................................
    Continuous abdominal pain with intermittent                       60
     vomiting, recurrent hematemesis (vomiting blood) or
     melena (tarry stools); and manifestations of anemia
     which require hospitalization at least once in the
     past 12 months.....................................
    Episodes of abdominal pain, nausea, or vomiting,                  40
     that: last for at least three consecutive days in
     duration; occur four or more times in the past 12
     months; and are managed by daily prescribed
     medication.........................................
    Episodes of abdominal pain, nausea, or vomiting,                  20
     that: last for at least three consecutive days in
     duration; occur three times or less in the past 12
     months; and are managed by daily prescribed
     medication.........................................
    History of peptic ulcer disease documented by                      0
     endoscopy or diagnostic imaging studies............
    Note: After three months at the 100% evaluation,
     rate on residuals as determined by mandatory VA
     medical examination. Apply the provisions of Sec.
     3.105(e) of this chapter to any change in
     evaluation based upon that or any subsequent
     examination.
7307 Gastritis, chronic:
    Rate as peptic ulcer disease (DC 7304).
    Note: This diagnostic code includes Helicobacter
     pylori infection, drug-induced gastritis, Zollinger-
     Ellison syndrome, and portal-hypertensive
     gastropathy with varix-related complications.
7308 Postgastrectomy syndrome:
    Rate residuals as chronic complications of upper
     gastrointestinal surgery (DC 7303).
7309 Stomach, stenosis of:
    Rate as chronic complications of upper
     gastrointestinal surgery (DC 7303) or peptic ulcer
     disease (DC 7304), depending on the predominant
     disability.
7310 Stomach, injury of, residuals:
    Pre-operative: Rate as adhesions of peritoneum due
     to surgery, trauma, disease, or infection (DC
     7301). No adhesions are necessary when evaluating
     under DC 7301.
    Post-operative: Rate as chronic complications of
     upper gastrointestinal surgery (DC 7303).
 
                              * * * * * * *
7312 Cirrhosis of the liver:
    Liver disease with Model for End-Stage Liver Disease             100
     score greater than or equal to 15; or with
     continuous daily debilitating symptoms, generalized
     weakness and at least one of the following: (1)
     ascites (fluid in the abdomen), or (2) a history of
     spontaneous bacterial peritonitis, or (3) hepatic
     encephalopathy, or (4) variceal hemorrhage, or (5)
     coagulopathy, or (6) portal gastropathy, or (7)
     hepatopulmonary or hepatorenal syndrome............
    Liver disease with Model for End-Stage Liver Disease              60
     score greater than 11 but less than 15; or with
     daily fatigue and at least one episode in the last
     year of either (1) variceal hemorrhage, or (2)
     portal gastropathy or hepatic encephalopathy.......
    Liver disease with Model for End-Stage Liver Disease              30
     score of 10 or 11; or with signs of portal
     hypertension such as splenomegaly or ascites (fluid
     in the abdomen) and either weakness, anorexia,
     abdominal pain, or malaise.........................
    Liver disease with Model for End-Stage Liver Disease              10
     score greater than 6 but less than 10; or with
     evidence of either anorexia, weakness, abdominal
     pain or malaise....................................
    Asymptomatic, but with a history of liver disease...               0
    Note (1): Rate hepatocellular carcinoma occurring
     with cirrhosis under DC 7343 (Malignant neoplasms
     of the digestive system, exclusive of skin growths)
     in lieu of DC 7312.
    Note (2): Biochemical studies, imaging studies, or
     biopsy must confirm liver dysfunction (including
     hyponatremia, thrombocytopenia, and/or
     coagulopathy).
    Note (3): Rate condition based on symptomatology
     where the evidence does not contain a Model for End-
     Stage Liver Disease score.
7314 Chronic biliary tract disease:
    With three or more clinically documented attacks of               30
     right upper quadrant pain with nausea and vomiting
     during the past 12 months; or requiring dilatation
     of biliary tract strictures at least once during
     the past 12 months.
    With one or two clinically documented attacks of                  10
     right upper quadrant pain with nausea and vomiting
     in the past 12 months.

[[Page 19746]]

 
    Asymptomatic, without history of a clinically                      0
     documented attack of right upper quadrant pain with
     nausea and vomiting in the past 12 months.
    Note: This diagnostic code includes cholangitis,
     biliary strictures, Sphincter of Oddi dysfunction,
     bile duct injury, and choledochal cyst. Rate
     primary sclerosing cholangitis under chronic liver
     disease without cirrhosis (DC 7345).
7315 Cholelithiasis, chronic:
    Rate as chronic biliary tract disease (DC 7314).
7317 Gallbladder, injury of:
    Rate as adhesions of the peritoneum due to surgery,
     trauma, disease, or infection (DC 7301); or chronic
     gallbladder and biliary tract disease (DC 7314), or
     cholecystectomy (gallbladder removal),
     complications of (such as strictures and biliary
     leaks) (DC 7318), depending on the predominant
     disability.
    Note: When rating gallbladder injuries analogous to
     DC 7301, a finding of adhesions is not necessary.
7318 Cholecystectomy (gallbladder removal),
 complications of (such as strictures and biliary
 leaks):
    With recurrent abdominal pain (post-prandial or                   30
     nocturnal); and chronic diarrhea characterized by
     three or more watery bowel movements per day.......
    With intermittent abdominal pain; and diarrhea                    10
     characterized by one to two watery bowel movements
     per day............................................
    Asymptomatic........................................               0
7319 Irritable bowel syndrome (IBS):
    Abdominal pain related to defecation at least one                 30
     day per week during the previous three months; and
     two or more of the following: (1) change in stool
     frequency, (2) change in stool form, (3) altered
     stool passage (straining and/or urgency), (4)
     mucorrhea, (5) abdominal bloating, or (6)
     subjective distension..............................
    Abdominal pain related to defecation for at least                 20
     three days per month during the previous three
     months; and two or more of the following: (1)
     change in stool frequency, (2) change in stool
     form, (3) altered stool passage (straining and/or
     urgency), (4) mucorrhea, (5) abdominal bloating, or
     (6) subjective distension..........................
    Abdominal pain related to defecation at least once                10
     during the previous three months; and two or more
     of the following: (1) change in stool frequency,
     (2) change in stool form, (3) altered stool passage
     (straining and/or urgency), (4) mucorrhea, (5)
     abdominal bloating, or (6) subjective distension...
    Note: This diagnostic code may include functional
     digestive disorders (see Sec.   3.317 of this
     chapter), such as dyspepsia, functional bloating
     and constipation, and diarrhea. Evaluate other
     symptoms of a functional digestive disorder not
     encompassed by this diagnostic code under the
     appropriate diagnostic code, to include
     gastrointestinal dysmotility syndrome (DC 7356),
     following the general principles of Sec.   4.14 and
     this section.
7323 Colitis, ulcerative:
    Rate as Crohn's disease or undifferentiated form of
     inflammatory bowel disease (DC 7326).
7325 Enteritis, chronic:
    Rate as Irritable Bowel Syndrome (DC 7319) or
     Crohn's disease or undifferentiated form of
     inflammatory bowel disease (DC 7326), depending on
     the predominant disability.
7326 Crohn's disease or undifferentiated form of
 inflammatory bowel disease:
    Severe inflammatory bowel disease that is                        100
     unresponsive to treatment; and requires
     hospitalization at least once per year; and results
     in either an inability to work or is characterized
     by recurrent abdominal pain associated with at
     least two of the following: (1) six or more
     episodes per day of diarrhea, (2) six or more
     episodes per day of rectal bleeding, (3) recurrent
     episodes of rectal incontinence, or (4) recurrent
     abdominal distension...............................
    Moderate inflammatory bowel disease that is managed               60
     on an outpatient basis with immunosuppressants or
     other biologic agents; and is characterized by
     recurrent abdominal pain, four to five daily
     episodes of diarrhea; and intermittent signs of
     toxicity such as fever, tachycardia, or anemia.....
    Mild to moderate inflammatory bowel disease that is               30
     managed with oral and topical agents (other than
     immunosuppressants or other biologic agents); and
     is characterized by recurrent abdominal pain with
     three or less daily episodes of diarrhea and
     minimal signs of toxicity such as fever,
     tachycardia, or anemia.............................
    Minimal to mild symptomatic inflammatory bowel                    10
     disease that is managed with oral or topical agents
     (other than immunosuppressants or other biologic
     agents); and is characterized by recurrent
     abdominal pain with three or less daily episodes of
     diarrhea and no signs of systemic toxicity.........
    Note (1): Following colectomy/colostomy with
     persistent or recurrent symptoms, rate either under
     DC 7326 or DC 7329 (Intestine, large, resection
     of), whichever provides the highest rating.
    Note (2): VA requires diagnoses under DC 7326 to be
     confirmed by endoscopy or radiologic studies.
    Note (3): Inflammation may involve small bowel
     (ileitis), large bowel (colitis), or inflammation
     of any component of the gastrointestinal tract from
     the mouth to the anus.
7327 Diverticulitis and diverticulosis:
    Diverticular disease requiring hospitalization for                30
     abdominal distress, fever, and leukocytosis
     (elevated white blood cells) one or more times in
     the past 12 months; and with at least one of the
     following complications: (1) hemorrhage, (2)
     obstruction, (3) abscess, (4) peritonitis, or (5)
     perforation........................................
    Diverticular disease requiring hospitalization for                20
     abdominal distress, fever, and leukocytosis
     (elevated white blood cells) one or more times in
     the past 12 months; and without associated (1)
     hemorrhage, (2) obstruction, (3) abscess, (4)
     peritonitis, or (5) perforation....................
    Asymptomatic; or a symptomatic diverticulitis or                   0
     diverticulosis that is managed by diet and
     medication.........................................
    Note: For colectomy or colostomy, use DC 7327 or DC
     7329 (Intestine, large, resection of), whichever
     results in a higher evaluation.
7328 Intestine, small, resection of:
    Status post intestinal resection with undernutrition              80
     and anemia; and requiring total parenteral
     nutrition (TPN)....................................
    Status post intestinal resection with undernutrition              60
     and anemia; and requiring prescribed oral dietary
     supplementation, continuous medication and
     intermittent total parenteral nutrition (TPN)......
    Status post intestinal resection with four or more                40
     episodes of diarrhea per day resulting in
     undernutrition and anemia; and requiring prescribed
     oral dietary supplementation and continuous
     medication.........................................
    Status post intestinal resection with four or more                20
     episodes of diarrhea per day.......................
    Status post intestinal resection, asymptomatic......               0

[[Page 19747]]

 
    Note: This diagnostic code includes short bowel
     syndrome, mesenteric ischemic thrombosis, and post-
     bariatric surgery complications. Where short bowel
     syndrome results in high-output syndrome, to
     include high-output stoma, consider assigning a
     higher evaluation under DC 7329 (Intestine, large,
     resection of).
7329 Intestine, large, resection of:
    Total colectomy with formation of ileostomy, high-               100
     output syndrome, and more than two episodes of
     dehydration requiring intravenous hydration in the
     past 12 months.....................................
    Total colectomy with or without permanent colostomy               60
     or ileostomy without high-output syndrome..........
    Partial colectomy with permanent colostomy or                     40
     ileostomy without high-output syndrome.............
    Partial colectomy with reanastomosis (reconnection                20
     of the intestinal tube) with loss of ileocecal
     valve and recurrent episodes of diarrhea more than
     3 times per day....................................
    Partial colectomy with reanastomosis (reconnection                10
     of the intestinal tube)............................
7330 Intestinal fistulous disease, external:
    Requiring total parenteral nutrition (TPN); or                   100
     enteral nutritional support along with at least one
     of the following: (1) daily discharge equivalent to
     four or more ostomy bags (sized 130 cc), (2)
     requiring ten or more pad changes per day, or (3) a
     Body Mass Index (BMI) less than 16 and persistent
     drainage (any amount) for more than 1 month during
     the past 12 months.................................
    Requiring enteral nutritional support along with at               60
     least one of the following: (1) daily discharge
     equivalent to three or less ostomy bags (sized 130
     cc), (2) requiring fewer than ten pad changes per
     day, or (3) a Body Mass Index (BMI) of 16 to 18
     inclusive and persistent drainage (any amount) for
     more than 2 months in the past 12 months...........
    Intermittent fecal discharge with persistent                      30
     drainage for more than 3 months in the past 12
     months.............................................
    Note: This code applies to external fistulas that
     have developed as a consequence of abdominal
     trauma, surgery, radiation, malignancy, infection,
     or ischemia.
 
                              * * * * * * *
7332 Rectum and anus, impairment of sphincter control:
    Complete loss of sphincter control characterized by              100
     incontinence or retention that is not responsive to
     a physician-prescribed bowel program and requires
     either surgery or digital stimulation, medication
     (beyond laxative use), and special diet; or
     incontinence to solids and/or liquids two or more
     times per day, which requires changing a pad two or
     more times per day.................................
    Complete or partial loss of sphincter control                     60
     characterized by incontinence or retention that is
     partially responsive to a physician-prescribed
     bowel program and requires either surgery or
     digital stimulation, medication (beyond laxative
     use), and special diet; or incontinence to solids
     and/or liquids two or more times per week, which
     requires wearing a pad two or more times per week..
    Complete or partial loss of sphincter control                     30
     characterized by incontinence or retention that is
     fully responsive to a physician-prescribed bowel
     program and requires digital stimulation,
     medication (beyond laxative use), and special diet;
     or incontinence to solids and/or liquids two or
     more times per month, which requires wearing a pad
     two or more times per month........................
    Complete or partial loss of sphincter control                     10
     characterized by incontinence or retention that is
     fully responsive to a physician-prescribed bowel
     program and requires medication or special diet; or
     incontinence to solids and/or liquids at least once
     every six months, which requires wearing a pad at
     least once every six months........................
    History of loss of sphincter control, currently                    0
     asymptomatic.......................................
    Note: Complete or partial loss of sphincter control
     refers to the inability to retain or expel stool at
     an appropriate time and place.
7333 Rectum and anus, stricture of:
    Inability to open the anus with inability to expel               100
     solid feces........................................
    Reduction of the lumen 50% or more, with pain and                 60
     straining during defecation........................
    Reduction of the lumen by less than 50%, with                     30
     straining during defecation........................
    Luminal narrowing with or without straining, managed              10
     by dietary intervention............................
    Note (1): Conditions rated under this code include
     dyssynergic defecation (levator ani) and anismus
     (functional constipation)..........................
    Note (2): Evaluate an ostomy as Intestine, large,
     resection of (DC 7329).............................
7334 Rectum, prolapse of:
    Persistent irreducible prolapse, repairable or                   100
     unrepairable.......................................
    Manually reducible prolapse that is not repairable                50
     and occurs at times other than bowel movements,
     exertion, or while performing the Valsalva maneuver
    Manually reducible prolapse that is not repairable                30
     and occurs only after bowel movements, exertion, or
     while performing the Valsalva maneuver.............
    Spontaneously reducible prolapse that is not                      10
     repairable.........................................
    Note (1): For repairable prolapse of the rectum,
     continue the 100% evaluation for two months
     following repair. Thereafter, determine the
     appropriate evaluation based on residuals by
     mandatory VA examination. Apply the provisions of
     Sec.   3.105(e) of this chapter to any change in
     evaluation based upon that or any subsequent
     examination.
    Note (2): Where impairment of sphincter control
     constitutes the predominant disability, rate under
     diagnostic code 7332 (Rectum and anus, impairment
     of sphincter control).
7335 Ano, fistula in, including anorectal fistula and
 anorectal abscess:
    More than two constant or near-constant fistulas                  60
     with abscesses, drainage, and pain, which are
     refractory to medical and surgical treatment.......
    One or two simultaneous fistulas, with abscess,                   40
     drainage, and pain.................................
    Two or more simultaneous fistulas with drainage and               20
     pain, but without abscesses........................
    One fistula with drainage and pain, but without                   10
     abscess............................................
7336 Hemorrhoids, external or internal:
    Internal or external hemorrhoids with persistent                  20
     bleeding and anemia; or continuously prolapsed
     internal hemorrhoids with three or more episodes
     per year of thrombosis.............................
    Prolapsed internal hemorrhoids with two or less                   10
     episodes per year of thrombosis; or external
     hemorrhoids with three or more episodes per year of
     thrombosis.........................................

[[Page 19748]]

 
7337 Pruritus ani (anal itching):
    With bleeding or excoriation........................              10
    Without bleeding or excoriation.....................               0
7338 Hernia, including femoral, inguinal, umbilical,
 ventral, incisional, and other (but not including
 hiatal).
    Irreparable hernia (new or recurrent) present for 12
     months or more; with both of the following present
     for 12 months or more:
    1. Size equal to 15 cm or greater in one dimension;
     and
    2. Pain when performing at least three of the                    100
     following activities: (1) bending over, (2)
     activities of daily living (ADLs), (3) walking, and
     (4) climbing stairs................................
    Irreparable hernia (new or recurrent) present for 12
     months or more; with both of the following present
     for 12 months or more:
    1. Size equal to 15 cm or greater in one dimension;
     and
    2. Pain when performing two of the following                      60
     activities: (1) bending over, (2) activities of
     daily living (ADLs), (3) walking, and (4) climbing
     stairs.............................................
    Irreparable hernia (new or recurrent) present for 12
     months or more; with both of the following present
     for 12 months or more:
    1. Size equal to 3 cm or greater but less than 15 cm
     in one dimension; and
    2. Pain when performing at least two of the                       30
     following activities: (1) bending over, (2)
     activities of daily living (ADLs), (3) walking, and
     (4) climbing stairs................................
    Irreparable hernia (new or recurrent) present for 12
     months or more; with both of the following present
     for 12 months or more:
    1. Size equal to 3 cm or greater but less than 15 cm
     in one dimension; and
    2. Pain when performing one of the following                      20
     activities: (1) bending over, (2) activities of
     daily living (ADLs), (3) walking, and (4) climbing
     stairs.............................................
    Irreparable hernia (new or recurrent) present for 12              10
     months or more; with hernia size smaller than 3 cm.
    Asymptomatic hernia; present and repairable, or                    0
     repaired...........................................
    Note (1): With two compensable inguinal hernias,
     evaluate the more severely disabling hernia first,
     and then add 10% to that rating to account for the
     second compensable hernia. Do not add 10% to that
     rating if the more severely disabling hernia is
     rated at 100%.
    Note (2): Any one of the following activities of
     daily living are sufficient for evaluation:
     bathing, dressing, hygiene, and/or transfers.
 
                              * * * * * * *
7344 Benign neoplasms, exclusive of skin growths:
    Evaluate under a diagnostic code appropriate to the
     predominant disability or the specific residuals
     after treatment.
    Note: This diagnostic code includes lipoma,
     leiomyoma, colon polyps, or villous adenoma.
7345 Chronic liver disease without cirrhosis:
    Progressive chronic liver disease requiring use of               100
     both parenteral antiviral therapy (direct antiviral
     agents), and parenteral immunomodulatory therapy
     (interferon and other); and for six months
     following discontinuance of treatment..............
    Progressive chronic liver disease requiring                       60
     continuous medication and causing substantial
     weight loss and at least two of the following: (1)
     daily fatigue, (2) malaise, (3) anorexia, (4)
     hepatomegaly, (5) pruritus, and (6) arthralgia.....
    Progressive chronic liver disease requiring                       40
     continuous medication and causing minor weight loss
     and at least two of the following: (1) daily
     fatigue, (2) malaise, (3) anorexia, (4)
     hepatomegaly, (5) pruritus, and (6) arthralgia.....
    Chronic liver disease with at least one of the                    20
     following: (1) intermittent fatigue, (2) malaise,
     (3) anorexia, (4) hepatomegaly, or (5) pruritus....
    Previous history of liver disease, currently                       0
     asymptomatic.......................................
    Note (1): 100% evaluation shall continue for six
     months following discontinuance of parenteral
     antiviral therapy and administration of parenteral
     immunomodulatory drugs. Six months after
     discontinuance of parenteral antiviral therapy and
     parenteral immunomodulatory drugs, determine the
     appropriate disability rating by mandatory VA exam.
     Apply the provisions of Sec.   3.105(e) of this
     chapter to any change in evaluation based upon that
     or any subsequent examination.
    Note (2): For individuals for whom physicians
     recommend both parenteral antiviral therapy and
     parenteral immunomodulatory drugs, but for whom
     treatment is medically contraindicated, rate
     according to DC 7312 (Cirrhosis of the liver).
    Note (3): This diagnostic code includes Hepatitis B
     (confirmed by serologic testing), primary biliary
     cirrhosis (PBC), primary sclerosing cholangitis
     (PSC), autoimmune liver disease, Wilson's disease,
     Alpha-1-antitrypsin deficiency, hemochromatosis,
     drug-induced hepatitis, and non-alcoholic
     steatohepatitis (NASH). Track Hepatitis C (or non-
     A, non-B hepatitis) under DC 7354 but evaluate it
     using the criteria in this entry.
    Note (4): Evaluate sequelae, such as cirrhosis or
     malignancy of the liver, under an appropriate
     diagnostic code, but do not use the same signs and
     symptoms as the basis for evaluation under DC 7354
     and under a diagnostic code for sequelae. (See Sec.
       4.14)
7346 Hiatal hernia and paraesophageal hernia:
    Rate as esophagus, stricture of (DC 7203).
7347 Pancreatitis, chronic:
    Daily episodes of abdominal or mid-back pain that                100
     require three or more hospitalizations per year;
     and pain management by a physician; and
     maldigestion and malabsorption requiring dietary
     restriction and pancreatic enzyme supplementation..
    Three or more episodes of abdominal or mid-back pain              60
     per year and at least one episode per year
     requiring hospitalization for management either of
     complications related to abdominal pain or
     complications of tube enteral feeding..............
    At least one episode per year of abdominal or mid-                30
     back pain that requires ongoing outpatient medical
     treatment for pain, digestive problems, or
     management of related complications including but
     not limited to cyst, pseudocyst, intestinal
     obstruction, or ascites............................
    Note (1): Appropriate diagnostic studies must
     confirm that abdominal pain in this condition
     results from pancreatitis.
    Note (2): Separately rate endocrine dysfunction
     resulting in diabetes due to pancreatic
     insufficiency under DC 7913 (Diabetes mellitus).
7348 Vagotomy with pyloroplasty or gastroenterostomy:

[[Page 19749]]

 
    Following confirmation of postoperative                           40
     complications of stricture or continuing gastric
     retention..........................................
    With symptoms and confirmed diagnosis of alkaline                 30
     gastritis, or with confirmed persisting diarrhea...
    With incomplete vagotomy............................              20
    Note: Rate recurrent ulcer following complete
     vagotomy under DC 7304 (Peptic ulcer disease), with
     a minimum rating of 20%; and rate post-operative
     residuals not addressed by this diagnostic code
     under DC 7303 (Chronic complications of upper
     gastrointestinal surgery).
7350 Liver abscess:
    Assign a rating of 100% for 6 months from the date
     of initial diagnosis. Six months following initial
     diagnosis, determine the appropriate disability
     rating by mandatory VA examination. Thereafter,
     rate the condition based on chronic residuals under
     the appropriate body system. Apply the provisions
     of Sec.   3.105(e) of this chapter to any reduction
     in evaluation.
    Note: This diagnostic code includes abscesses caused
     by bacterial, viral, amebic (e.g., E. hystolytica),
     fungal (e.g., C. albicans), and other agents.
7351 Liver transplant:
    For an indefinite period from the date of hospital               100
     admission for transplant surgery...................
    Eligible and awaiting transplant surgery, minimum                 60
     rating.............................................
    Following transplant surgery, minimum rating........              30
    Note: Assign a rating of 100% as of the date of
     hospital admission for transplant surgery. One year
     following discharge, determine the appropriate
     disability rating by mandatory VA examination.
     Apply the provisions of Sec.   3.105(e) of this
     chapter to any change in evaluation based upon that
     or any subsequent examination. Rate residuals of
     any recurrent underlying liver disease under the
     appropriate diagnostic code and, when appropriate,
     combine with other post-transplant residuals under
     the appropriate body system(s), subject to the
     provisions of Sec.   4.14 and this section.
7352 Pancreas transplant:
    For an indefinite period from the date of hospital               100
     admission for transplant surgery...................
    Minimum rating......................................              30
    Note: Assign a rating of 100% as of the date of
     hospital admission for transplant surgery. One year
     following discharge, determine the appropriate
     disability rating by mandatory VA examination.
     Apply the provisions of Sec.   3.105(e) of this
     chapter to any change in evaluation based upon that
     or any subsequent examination.
7354 Hepatitis C (or non-A, non-B hepatitis):
    Rate under DC 7345 (Chronic liver disease without
     cirrhosis).
7355 Celiac disease:
    Malabsorption syndrome with weakness which                        80
     interferes with activities of daily living; and
     weight loss resulting in wasting and nutritional
     deficiencies; and with systemic manifestations
     including but not limited to, weakness and fatigue,
     dermatitis, lymph node enlargement, hypocalcemia,
     low vitamin levels; and anemia related to
     malabsorption; and episodes of abdominal pain and
     diarrhea due to lactase deficiency or pancreatic
     insufficiency......................................
    Malabsorption syndrome with chronic diarrhea managed              50
     by medically-prescribed dietary intervention such
     as prescribed gluten-free diet, with nutritional
     deficiencies due to lactase and pancreatic
     insufficiency; and with systemic manifestations
     including, but not limited to, weakness and
     fatigue, dermatitis, lymph node enlargement,
     hypocalcemia, low vitamin levels, or atrophy of the
     inner intestinal lining shown on biopsy............
    Malabsorption syndrome with chronic diarrhea managed              30
     by medically-prescribed dietary intervention such
     as prescribed gluten-free diet; and without
     nutritional deficiencies...........................
    Note (1): An appropriate serum antibody test or
     endoscopy with biopsy must confirm the diagnosis.
    Note (2): For evaluation of celiac disease with the
     predominant disability of malabsorption, use the
     greater evaluation between DC 7328 or celiac
     disease under DC 7355.
7356 Gastrointestinal dysmotility syndrome:
    Requiring complete dependence on total parenteral                 80
     nutrition (TPN) or continuous tube feeding for
     nutritional support................................
    Requiring intermittent tube feeding for nutritional               50
     support; with recurrent emergency treatment for
     episodes of intestinal obstruction or regurgitation
     due to poor gastric emptying, abdominal pain,
     recurrent nausea, or recurrent vomiting............
    With symptoms of chronic intestinal pseudo-                       30
     obstruction (CIPO) or symptoms of intestinal
     motility disorder, including but not limited to,
     abdominal pain, bloating, feeling of epigastric
     fullness, dyspepsia, nausea and vomiting,
     regurgitation, constipation, and diarrhea, managed
     by ambulatory care; and requiring prescribed
     dietary management or manipulation.................
    Intermittent abdominal pain with epigastric fullness              10
     associated with bloating; and without evidence of a
     structural gastrointestinal disease................
    Note: Use this diagnostic code for illnesses
     associated with Sec.   3.317(a)(2)(i)(B)(3) of this
     chapter, other than those which can be evaluated
     under DC 7319.
7357 Post pancreatectomy syndrome:
    Following total or partial pancreatectomy, evaluate
     under Pancreatitis, chronic (DC 7347), Chronic
     complications of upper gastrointestinal surgery (DC
     7303), or based on residuals such as malabsorption
     (Intestine, small, resection of, DC 7328), diarrhea
     (Irritable bowel syndrome, DC 7319, or Crohn's
     disease or undifferentiated form of inflammatory
     bowel disease, DC 7326), or diabetes (DC 7913),
     whichever provides the highest evaluation..........
    Minimum.............................................              30
------------------------------------------------------------------------

* * * * *


0
6. Amend appendix A to part 4 by:
0
a. Adding entries in numerical order for Sec. Sec.  4.110, 4.111, and 
4.112; and
0
b. Revising and republishing the entry for Sec.  4.114.
    The additions and revision read as follows:

[[Page 19750]]



Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                                   Diagnostic
              Sec.                  code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.110..........................  ..............  Removed and reserved
                                                  May 19, 2024.
4.111..........................  ..............  Removed and reserved
                                                  May 19, 2024.
4.112..........................  ..............  Revised May 19, 2024.
 
                              * * * * * * *
4.114..........................  ..............  Introduction paragraph
                                                  revised March 10,
                                                  1976; introduction
                                                  paragraph revised May
                                                  19, 2024.
                                           7200  Title, criterion May
                                                  19, 2024.
                                           7201  Criterion May 19, 2024.
                                           7202  Evaluation, criterion,
                                                  note May 19, 2024.
                                           7203  Evaluation, criterion,
                                                  note May 19, 2024.
                                           7204  Title, note May 19,
                                                  2024.
                                           7205  Note May 19, 2024.
                                           7206  Added May 19, 2024.
                                           7207  Added May 19, 2024.
                                           7301  Title, Evaluation,
                                                  criterion, note May
                                                  19, 2024.
                                           7302  Removed April 8, 1959.
                                           7303  Added May 19, 2024.
                                           7304  Evaluation November 1,
                                                  1962; title,
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7305  Evaluation November 1,
                                                  1962; Removed May 19,
                                                  2024.
                                           7306  Criterion April 8,
                                                  1959; Removed May 19,
                                                  2024.
                                           7307  Evaluation May 22,
                                                  1964; Criterion May
                                                  22, 1964; Note May 22,
                                                  1964; title,
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7308  Title April 8, 1959;
                                                  evaluation April 8,
                                                  1959; evaluation and
                                                  criterion May 19,
                                                  2024.
                                           7309  Evaluation May 19,
                                                  2024.
                                           7310  Evaluation May 19,
                                                  2024.
                                           7311  Criterion July 2, 2001.
                                           7312  Evaluation March 10,
                                                  1976; evaluation July
                                                  2, 2001; title,
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7313  Evaluation March 10,
                                                  1976; removed July 2,
                                                  2001.
                                           7314  Title, evaluation, note
                                                  May 19, 2024.
                                           7315  Evaluation May 19,
                                                  2024.
                                           7316  Removed May 19, 2024.
                                           7317  Note May 19, 2024.
                                           7318  Title, evaluation, and
                                                  criterion May 19,
                                                  2024.
                                           7319  Title November 1, 1962;
                                                  evaluation November 1,
                                                  1962; title,
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7321  Evaluation July 6,
                                                  1950; criterion March
                                                  10, 1976; Removed May
                                                  19, 2024.
                                           7322  Removed May 19, 2024.
                                           7323  Criterion and note May
                                                  19, 2024.
                                           7324  Removed May 19, 2024.
                                           7325  Note November 1, 1962;
                                                  note May 19, 2024.
                                           7326  Note November 1, 1962;
                                                  title, evaluation,
                                                  criterion and note May
                                                  19, 2024.
                                           7327  Evaluation November 1,
                                                  1962; criterion
                                                  November 1, 1962; note
                                                  November 1, 1962;
                                                  title, evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7328  Evaluation November 1,
                                                  1962; title,
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7329  Evaluation November 1,
                                                  1962; evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7330  Evaluation November 1,
                                                  1962; criterion and
                                                  note May 19, 2024.
                                           7331  Criterion March 11,
                                                  1969.
                                           7332  Evaluation November 1,
                                                  1962; evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7333  Evaluation, criterion,
                                                  and note May 19, 2024.
                                           7334  Evaluation July 6,
                                                  1950; evaluation
                                                  November 1, 1962;
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7335  Evaluation and
                                                  criterion May 19,
                                                  2024.
                                           7336  Criterion November 1,
                                                  1962; criterion May
                                                  19, 2024.
                                           7337  Title, evaluation, and
                                                  criterion May 19,
                                                  2024.
                                           7338  Title, evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7339  Criterion March 10,
                                                  1976; removed May 19,
                                                  2024.
                                           7340  Removed May 19, 2024.
                                           7341  Removed March 10, 1976.
                                           7343  Criterion March 10,
                                                  1976; criterion July
                                                  2, 2001.
                                           7344  Criterion July 2, 2001;
                                                  note May 19, 2024.
                                           7345  Evaluation August 23,
                                                  1948; evaluation
                                                  February 17, 1955;
                                                  evaluation July 2,
                                                  2001; title May 19,
                                                  2024; evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7346  Evaluation February 1,
                                                  1962; title May 19,
                                                  2024; evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7347  Added September 9,
                                                  1975; title May 19,
                                                  2024; evaluation,
                                                  criterion, and note
                                                  May 19, 2024.
                                           7348  Added March 10, 1976;
                                                  criterion and note May
                                                  19, 2024.
                                           7350  Added May 19, 2024.
                                           7351  Added July 2, 2001;
                                                  evaluation, criterion,
                                                  and note May 19, 2024.
                                           7352  Added May 19, 2024.
                                           7354  Added July 2, 2001;
                                                  evaluation, criterion,
                                                  and note May 19, 2024.

[[Page 19751]]

 
                                           7355  Added May 19, 2024.
                                           7356  Added May 19, 2024.
                                           7357  Added May 19, 2024.
 
                              * * * * * * *
------------------------------------------------------------------------


0
7. Amend appendix B to part 4 by revising and republishing the entries 
in the table under ``The Digestive System'' to read as follows:

          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
         Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
                          The Digestive System
------------------------------------------------------------------------
7200.................................  Soft tissue injury of the mouth,
                                        other than tongue or lips.
7201.................................  Lips, injuries.
7202.................................  Tongue, loss of whole or part.
7203.................................  Esophagus, stricture.
7204.................................  Esophageal motility disorder.
7205.................................  Esophagus, diverticulum.
7206.................................  Gastroesophageal reflux disease.
7207.................................  Barrett's esophagus.
7301.................................  Peritoneum, adhesions of, due to
                                        surgery, trauma, or infection.
7303.................................  Chronic complications of upper
                                        gastrointestinal surgery.
7304.................................  Peptic ulcer disease.
7305.................................  [Removed].
7306.................................  [Removed].
7307.................................  Gastritis, chronic.
7308.................................  Postgastrectomy syndromes.
7309.................................  Stomach, stenosis.
7310.................................  Stomach, injury of, residuals.
7311.................................  Liver, injury of, residuals.
7312.................................  Cirrhosis of the liver.
7314.................................  Chronic biliary tract disease.
7315.................................  Cholelithiasis, chronic.
7316.................................  [Removed].
7317.................................  Gallbladder, injury of.
7318.................................  Cholecystectomy (gallbladder
                                        removal), complications of (such
                                        as strictures and biliary
                                        leaks).
7319.................................  Irritable bowel syndrome (IBS).
7321.................................  [Removed].
7322.................................  [Removed].
7323.................................  Colitis, ulcerative.
7324.................................  [Removed].
7325.................................  Enteritis, chronic.
7326.................................  Crohn's disease or
                                        undifferentiated form of
                                        inflammatory bowel disease.
7327.................................  Diverticulitis and
                                        diverticulosis.
7328.................................  Intestine, small, resection of.
7329.................................  Intestine, large, resection.
7330.................................  Intestinal fistulous diseases,
                                        external.
7331.................................  Peritonitis.
7332.................................  Rectum and anus, impairment of
                                        sphincter control.
7333.................................  Rectum & anus, stricture.
7334.................................  Rectum, prolapse.
7335.................................  Ano, fistula in, including
                                        anorectal fistula, anorectal
                                        abscess.
7336.................................  Hemorrhoids, external or
                                        internal.
7337.................................  Pruritus ani (anal itching).
7338.................................  Hernia, including femoral,
                                        inguinal, umbilical, ventral,
                                        incisional, and other (but not
                                        including hiatal).
7339.................................  [Removed].
7340.................................  [Removed].
7342.................................  Visceroptosis.
7343.................................  Neoplasms, malignant.
7344.................................  Benign neoplasms, exclusive of
                                        skin growths.
7345.................................  Chronic liver disease without
                                        cirrhosis.
7346.................................  Hiatal hernia and paraesophageal
                                        hernia.
7347.................................  Pancreatitis, chronic.

[[Page 19752]]

 
7348.................................  Vagotomy with pyloroplasty or
                                        gastroenterostomy.
7350.................................  Liver abscess.
7351.................................  Liver transplant.
7352.................................  Pancreas transplant.
7354.................................  Hepatitis C (or non-A, non-B
                                        hepatitis).
7355.................................  Celiac disease.
7356.................................  Gastrointestinal dysmotility
                                        syndrome.
7357.................................  Post pancreatectomy syndrome.
 
                              * * * * * * *
------------------------------------------------------------------------


0
8. Amend appendix C to part 4 by:
0
a. Adding in alphabetical order under the entry for ``Abscess'', 
entries for ``Anorectal'' and ``Liver'';
0
b. Revising the entry for ``Cholangitis, chronic'';
0
c. Adding in alphabetical order an entry for ``Cholecystectomy 
(gallbladder removal), complications of (such as strictures and biliary 
leaks)'';
0
d. Adding in alphabetical order under the entry for ``Disease'', 
entries for ``Celiac'', ``Crohn's'', ``Gallbladder and biliary tract, 
chronic'', and ``Inflammatory bowel'';
0
e. Removing the entry for ``Diverticulitis'' and adding in its place an 
entry for ``Diverticulitis and diverticulosis'';
0
f. Adding in alphabetical order under the entry for ``Esophagus'', 
entries for ``Barrett's'' and ``Motility disorder'';
0
g. Removing the entry for ``Gastritis, hypertrophic'' and adding in its 
place an entry for ``Gastritis, chronic'';
0
h. Adding, in alphabetical order, an entry for ``Gastroesophageal 
reflux disease'';
0
i. Revising the entry for ``Hernia'';
0
j. Removing, under the entry for ``Injury'', the entries for ``Gall 
bladder'' and ``Mouth'' and adding in their place entries for 
``Gallbladder'' and ``Mouth, soft tissue'', respectively;
0
k. Removing the entry for ``Intestine, fistula of'' and adding in its 
place an entry for ``Intestine:'' and subentries for ``Fistulous 
disease, external'', ``Large, resection of'', and ``Small, resection 
of'';
0
l. Removing the entry for ``Irritable colon syndrome'' and adding in 
its place an entry for ``Irritable bowel syndrome (IBS)'';
0
m. Removing the entry for ``Pancreatitis'' and adding in its place an 
entry for ``Pancreas:'' and subentries for ``Chronic pancreatitis'', 
``Post pancreatectomy syndrome'', ``Surgery, complications of'', and 
``Transplant'';
0
n. Removing the entry for ``Pruritus ani'' and adding in its place an 
entry for ``Pruritus ani (anal itching)'';
0
o. Removing the entry for ``Stomach, stenosis of'' and adding in its 
place an entry for ``Stomach:'' and subentries for ``Postgastrectomy 
syndrome'', ``Stenosis of'', and ``Surgery, complications of'';
0
p. Adding in alphabetical order under the entry for ``Syndromes'', 
entries for ``Gastrointestinal dysmotility'', ``Postgastrectomy'', and 
``Post pancreatectomy''; and
0
q. Removing the entry for ``Ulcer'' and subentries ``Duodenal'', 
``Gastric'', and ``Marginal'' adding in their place an entry for 
``Ulcer, peptic''.
    The revisions and additions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Abscess:
    Anorectal...........................................            7335
 
                              * * * * * * *
    Liver...............................................            7350
 
                              * * * * * * *
 
                              * * * * * * *
Cholangitis, chronic....................................            7314
Cholecystectomy (gallbladder removal), complications of             7318
 (such as strictures and biliary leaks).................
 
                              * * * * * * *
Disease:
 
                              * * * * * * *
    Celiac..............................................            7355
 
                              * * * * * * *
    Crohn's.............................................            7326
    Gallbladder and biliary tract, chronic..............            7314
 
                              * * * * * * *
    Inflammatory bowel..................................            7326
 

[[Page 19753]]

 
                              * * * * * * *
 
                              * * * * * * *
    Diverticulitis and diverticulosis...................            7327
 
                              * * * * * * *
Esophagus:
    Barrett's...........................................            7207
 
                              * * * * * * *
    Motility disorder...................................            7204
 
                              * * * * * * *
 
                              * * * * * * *
Gastritis, chronic......................................            7307
Gastroesophageal reflux disease.........................            7206
 
                              * * * * * * *
Hernia:
    Femoral, inguinal, umbilical, ventral, incisional,              7338
     and other..........................................
    Hiatal and parasophageal............................            7346
    Muscle..............................................            5326
 
                              * * * * * * *
Injury:
 
                              * * * * * * *
    Gallbladder.........................................            7317
 
                              * * * * * * *
    Mouth, soft tissue..................................            7200
 
                              * * * * * * *
Intestine:
    Fistulous disease, external.........................            7330
    Large, resection of.................................            7329
    Small, resection of.................................            7328
    Irritable bowel syndrome (IBS)......................            7319
 
                              * * * * * * *
Pancreas:
    Chronic pancreatitis................................            7347
    Post pancreatectomy syndrome........................            7357
    Surgery, complications of...........................            7303
    Transplant..........................................            7352
 
                              * * * * * * *
    Pruritus ani (anal itching).........................            7337
 
                              * * * * * * *
Stomach:
    Postgastrectomy syndrome............................            7308
    Stenosis of.........................................            7309
    Surgery, complications of...........................            7303
 
                              * * * * * * *
Syndromes:
 
                              * * * * * * *
    Gastrointestinal dysmotility........................            7356
 
                              * * * * * * *
    Postgastrectomy.....................................            7308
    Post pancreatectomy.................................            7357
 
                              * * * * * * *
 
                              * * * * * * *
    Ulcer, peptic.......................................            7304
 

[[Page 19754]]

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

[FR Doc. 2024-05138 Filed 3-19-24; 8:45 am]
BILLING CODE 8320-01-P