Overview
In This Section |
This section contains the following topics:
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1. Selecting DCs
Introduction |
This topic includes information to supplement the regulatory provisions for selection of DCs to evaluate disabilities in the Department of Veterans Affairs (VA) Schedule for Rating Disabilities, including
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Change Date |
November 7, 2017
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III.iv.5.B.1.a. Choosing From Multiple Possible DCs |
Diagnostic codes (DCs) must be carefully selected and reasons for selection given if two or more are applicable. When multiple DCs apply to a given disability, consider
References: For more information on
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III.iv.5.B.1.b. Use of Hyphenated DCs |
Hyphenated DCs may be utilized for diseases or injuries. The use of a hyphenated DC is not intended to substitute for appropriate assignment of separate evaluations for different disabilities arising from a single injury.
References: For more information on the
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III.iv.5.B.1.c. When to Avoid Rating By Analogy |
Analogous ratings are utilized when a specific disability is not listed in 38 CFR Part 4, the Department of Veterans Affiars (VA) Schedule for Rating Disabilities. When a condition is specifically listed in the rating schedule, it may not be rated by analogy.
When there is a diagnosis of two separate conditions, apply the DC(s) that specifically pertains to the listed conditions and determine the appropriate disability evaluations.
Reference: For more information on analogous ratings, see
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III.iv.5.B.1.d. Impact of a Change in DC |
Service connection (SC) of a disability is not severed when the site of a disability or the DC associated with it is corrected to more accurately determine the benefit to which a Veteran may be entitled. The diagnosis or site of the existing service-connected (SC) condition may be corrected to accurately reflect the actual anatomical location of the injury or disease resulting in the Veteran’s disability, provided the redesignation does not result in severance of SC for the disability in question.
However, a change in DC cannot serve to reduce a protected disability evaluation where the symptoms upon which the evaluation was based are no longer present.
A change of diagnosis shown on examination or in other medical evidence must be reconciled to determine whether the underlying disability is the same condition or a progression of the condition that was previously diagnosed under a different diagnosis or whether a new disability, unrelated to the prior diagnosis, is being addressed.
Example 1: A Veteran is SC for gunshot wound (GSW) of the right thigh muscle group (MG) XIII under 38 CFR 4.73, DC 5313 with a 10-percent evaluation assigned based on moderate impairment. Subsequent evidence showed that the GSW actually impacted only MG XV, which is evaluated under 38 CFR 4.73, DC 5315 and that there was never an injury to or impairment of MG XIII. In this situation, since the correction of DC serves only to correct the site of the impairment and does not serve to effectively sever SC for an otherwise properly established disability, the change in DC is warranted.
Example 2: A Veteran is SC under 38 CFR 4.71a, DC 5257 for mild instability of the left knee shown on examination. The evaluation has been in place for over 20 years and is protected under 38 CFR 3.957. A claim for increase is received. The resultant examination shows no instability of the left knee but does show arthritis and pain related to the SC injury. In this situation, the 10-percent evaluation assigned under 38 CFR 4.71a, DC 5257 may not be reduced or eliminated. However, since there are separately compensable disabilities shown in the record, a separate evaluation for arthritis may be assigned under 38 CFR 4.71a, DC 5010.
References: For more information on
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III.iv.5.B.1.e. Handling a Change in Diagnosis |
38 CFR 4.13 directs that evidence suggesting a change in the diagnosis of an SC disability must be reviewed with a goal of reconciling the discrepancy and maintaining SC for the disability, where possible. Reconciliation is necessary to ensure
Refer to the table below for actions to take when a change in diagnosis of an SC disability is shown.
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2. Determining a Disability Evaluation Based on Rating Schedule Criteria
Introduction |
This topic includes general principles for determining a disability evaluation base on rating schedule criteria, including
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Change Date |
November 21, 2018
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III.iv.5.B.2.a. Relationships Within Evaluation Criteria |
In determining which fact findings are required to make a legal conclusion,generally if regulatory criteria are
The manner in which evaluation criteria relate to the lower and higher evaluation criteria within the same DC is also relevant when assigning evaluations.
Important:
References: For more information on
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III.iv.5.B.2.b. Separating Individual Findings and Pyramiding |
Do not separate individual findings when these findings, in their entirety, constitute one disability. This is
Note: Pyramiding is rating the same physical manifestations of a disability under two separate DCs. Separate evaluations are warranted where none of the symptomatology for any one condition duplicates or overlaps another (Esteban v. Brown, 6 Vet.App. 259, 261-62 (1994)).
Example 1: A disability of a tibia with malunion, limitation of dorsiflexion, eversion, inversion, and traumatic arthritis of the ankle would be evaluated under one DC, 38 CFR 4.71a, DC 5262, in accordance with the effect upon ankle function, with no separate evaluation for the limitation of motion or traumatic arthritis.
Example 2: A shoulder disability manifest as limitation of motion of the arm is entitled to a single rating under 38 CFR 4.71a, DC 5201, regardless of how many planes of motion are affected.
Example 3: Instability of the knee (38 CFR 4.71a, DC 5257) may be evaluated separately from limited motion of the knee due to arthritis (38 CFR 4.71a, DC 5003).
Reference: For more information on separating individual findings for knee disabilities, see
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III.iv.5.B.2.c. Evaluating Symptoms of SC and NSC Disabilities That Cannot Be Separated |
If it is not possible to separate the effects of an NSC condition from those of an SC condition, reasonable doubt, under 38 CFR 3.102, should be resolved in the Veteran’s favor with regard to whether certain signs and symptoms can be attributed to the SC condition.
When evaluating an SC disability for rating purposes, if it is not possible to differentiate the Veteran’s symptoms from an SC and NSC disability, all symptoms should be deemed related to the SC disability and rated accordingly.
Important:
References: For more information on
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III.iv.5.B.2.d. Considering Rating Criteria That Utilize “Such As” |
The use of the phrase “such symptoms as,” or a similar phrase, followed by a list of examples, provides guidance as to the variety of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and condition.
Reference: For more information on the use of the term “such symptoms as” in the schedule of ratings for mental disorders, see Mauerhan v. Principi, 16 Vet.App. 436 (2002).
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III.iv.5.B.2.e. Choosing Between Two Levels of Evaluation |
38 CFR 4.7 provides that where there is a question upon review of the evidence as to which of two evaluations shall be assigned, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.
Important: 38 CFR 4.7 does not preclude application of the reasonable doubt doctrine. When the decision maker concludes that the facts equally (or approximately equally) support two levels of evaluation such that each is as likely as not warranted, the higher evaluation will be awarded.
Reference: For more information on the application of variable, cumulative, and successive rating criteria and when 38 CFR 4.7 applies, see M21-1, Part III, Subpart iv, 5.B.2.a.
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III.iv.5.B.2.f. Assignment of Zero Percent Evaluations |
In every instance where the schedule does not provide a zero-percent evaluation for a DC, a zero-percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.
Reference: For more information on assignment of zero-percent evaluations, see38 CFR 4.31.
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III.iv.5.B.2.g. Assigning a 10-Percent Evaluation for Multiple Noncompensable SC Disabilities |
Under 38 CFR 3.324, a single 10-percent evaluation may be assigned when all of the following criteria are met:
Notes:
Reference: For more information on when to put into issue in a rating decision and decide entitlement to a 10-percent evaluation under 38 CFR 3.324, see M21-1, Part III, Subpart iv, 6.B.2.b.
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III.iv.5.B.2.h.Extra-schedular Evaluations Under 38 CFR 3.321(b)(1) |
38 CFR 3.321(b)(1) provides for referral for extra-schedular consideration based on the impact of a single disability.
Refer a claim to the Director of Compensation Service for a determination on whether an extra-schedular rating may be assigned when both of the following criteria are met:
Notes:
References: For more information on
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III.iv.5.B.2.i. Determining the Retroactive Applicability of a New Statute or Regulation |
The provisions of a statutory or regulatory change to rating schedule criteria for evaluating disabilities are generally not retroactive unless retroactive applicability is specifically directed. When a change that revises the rating schedule’s evaluation criteria does not specify the intent for retroactive application, assume that the new criteria do not apply prior to the effective date of the corresponding regulatory change.
Note: For claims pending on the date that a rating schedule provision is changed, it is usually appropriate to apply the
References: For more information on
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III.iv.5.B.2.j. Effect of Rating Schedule Readjustment |
When the rating schedule is readjusted, in no event shall the readjustment cause a Veteran’s disability evaluation in effect on the effective date of the readjustment to be reduced unless an improvement in the disability is shown to have occurred, even if the combined evaluation is not reduced, as indicated in VAOPGCPREC 19-1992, September 29, 1992, and 38 U.S.C. 1155.
This precedent opinion also provided that when a Veteran is receiving the minimum evaluation for a condition at the time the rating schedule is revised, and the condition subsequently undergoes an exacerbation resulting in a higher evaluation, if the condition returns to the same, symptom-free status it was in at the time of the rating schedule change, a noncompensable evaluation under the new criteria will be assigned.
Note: The February 3, 1988, revision of criteria for rating psychiatric disorders is considered a liberalizing law/VA issue as indicated in Sabol v. Derwinski, U.S. Vet.App. No. 90-1123 (1992), 38 U.S.C. 5110(g), 38 CFR 3.114, and VAOPGCPREC 19-1992.
Reference: For more information on protection and rating schedule changes, seeM21-1, Part III, Subpart iv, 8.C.4.
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III.iv.5.B.2.k. Assigning Staged Ratings |
The term staged rating refers to the assignment of separate ratings for separate periods of time based on the facts found.
38 CFR 3.105(e) does not apply to a staged rating. Additionally, 38 CFR 3.105(e)is inapplicable to disabilities rated under DCs containing a note that “any change in evaluation . . . shall be subject to the provisions of 38 CFR 3.105(e)” if the reduction is part of a staged rating assigned in the grant of an original claim for such disability.
Reference: For more information on assigning staged ratings, see
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3. Principles of Disability Evaluation for Specific Conditions
Introduction |
This topic contains information about evaluating specific conditions or circumstances, including |
Change Date |
January 4, 2018
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III.iv.5.B.3.a. Conceding Permanence for Evaluations |
38 CFR 3.327(b)(2), in part, directs that no periodic examination will be ordered
When evidence indicates that cancer or other similarly chronic and progressive disabilities are not expected to improve, concede permanence for the disability evaluation. Examples of indicators suggesting the likelihood that the disability status is permanent include but are not limited to
Note: If eligibility for Dependents Educational Assistance (DEA) is not being established as an ancillary benefit in the same rating decision (for example, when eligibility for DEA has been granted in a prior decision or is not warranted for a grant of benefits under 38 U.S.C. 1151), add free text to the rating narrative indicating that the assigned disability evaluation is considered permanent.
References: For more information on
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III.iv.5.B.3.b. Addressing the P&T Status of Malignancies |
VBMS-R’s system-generated language for evaluating totally disabling SC malignancies usually includes reference to the scheduling of a mandatory review examination intended to determine recurrence or residual disability.
When, however, P&T status of the SC malignancy has been conceded in light of the guidance in M21-1, Part III, Subpart iv, 5.B.3.a, edit the rating decision narrative by replacing the system-generated text displayed in the left column of the table below with the text displayed in the right column.
References: For more information on assigning P&T evaluations for
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III.iv.5.B.3.c. Evaluating Malignant Neoplasms and Associated Impairments |
Use the table below to determine whether a symptom or condition associated with an active malignant neoplasm may be separately evaluated during the period in which a 100-percent evaluation is warranted for the active malignant neoplasm.
Note: If doubt arises as to the medical cause or association of any symptoms or diagnosis, a medical opinion should be requested for clarification.
References: For more information on
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III.iv.5.B.3.d. Examples of Evaluating Diagnosed Disabilities Due to Malignant Neoplasms |
Example 1: SC for anxiety disorder claimed and diagnosed as secondary to active lung cancer may be granted and separately evaluated.
Example 2: A Veteran is SC with a 100-percent evaluation assigned for active renal cancer. He undergoes a nephrectomy as a part of the treatment for the renal cancer. 38 CFR 4.115b, DC 7528 directs that renal cancer is evaluated as active malignancy and its residuals are evaluated based on either voiding dysfunction or renal dysfunction. Since a nephrectomy is evaluated either with the minimum compensable evaluation or as renal dysfunction under 38 CFR 4.115b, DC 7500, the rating schedule recognizes that renal dysfunction is within the predominant symptomatology of both disabilities. Since both criteria contemplate renal dysfunction, the nephrectomy cannot be separately evaluated.
Example 3: A Veteran is SC with a 100-percent evaluation assigned for active renal cancer. He is diagnosed with recurrent pyelonephritis which is characterized by symptoms of recurrent urinary tract infection. The pyelonephritis is identified as a complication of the renal cancer. 38 CFR 4.115b, DC 7528 directs that renal cancer is evaluated as active malignancy and its residuals are evaluated based on either voiding dysfunction or renal dysfunction. Since the pyelonephritis is characterized by recurrent urinary tract infection, which is not considered within the criteria for evaluating malignant neoplasms of the genitourinary system, a separate evaluation may be assigned under 38 CFR 4.115b, DC 7504 utilizing the urinary tract infection symptoms.
Example 4: A Veteran is SC with a 100-percent evaluation assigned under 38 CFR 4.114, DC 7343 for active colon cancer. The Veteran sustained a nerve injury during surgery for the colon cancer resulting in impairment of anal sphincter control with incontinence. Since the symptoms of impairment of sphincter control with incontinence are due to a separately diagnosed disability (the nerve injury), pyramiding rules are not violated, and 38 CFR 4.114 does not prohibit separate evaluations for these coexisting digestive system disabilities, a separate evaluation may be assigned for the nerve injury with impairment of sphincter control under 38 CFR 4.114, DC 7332.
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Historical_M21-1III_iv_5_SecB_11-7-17.docx | May 15, 2019 | 83 KB |
Historical_M21-1III_iv_5_SecB_3-29-17.docx | May 15, 2019 | 75 KB |
11-7-17_Key-Changes_M21-1III_iv_5_SecB.docx | May 15, 2019 | 71 KB |
1-4-18_Key-Changes_M21-1III_iv_5_SecB.docx | May 15, 2019 | 74 KB |
Historical_M21-1III_iv_5_SecB_1-4-18.docx | May 15, 2019 | 88 KB |
4-19-18_Key-Changes_M21-1III_iv_5_SecB.docx | May 15, 2019 | 72 KB |
3-29-17_Key-Changes_M21-1III_iv_5_SecB.docx | May 15, 2019 | 67 KB |
11-21-18_Key-Changes_M21-1III_iv_5_SecB.docx | May 15, 2019 | 59 KB |
in Chapter 5 Evaluating Evidence and Making a Decision, Part III General Claims Process, Subpart iv General Rating Process
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