Title: Orthopedic Rating Principles
1Orthopedic Rating Principles
TDVA Annual Training
October 2013
2TDVA Annual Training
- Training will focus on the evaluations of knee
disabilities (including replacements) and spine
disabilities.
3Evaluation Considerations
- Functional Loss (38 CFR 4.40)
- DeLuca v. Brown, 1995
- Requires we consider not only limitation of
motion, but also - - weakened movement,
- - excess fatigability,
- - incoordination,
- - pain
- when evaluating these disabilities.
4Evaluation Considerations
- In Mitchell v. Shinseki, 25 Vet.App. 32 (2011),
the Veterans Court held that if pain is
associated with movement, the examiner must give
an opinion on whether pain could significantly
limit functional ability during flare-ups or when
the joint is used repeatedly over a period of
time and that such opinion, if feasible, be
expressed in terms of the degree of additional
range of motion (ROM) loss due to pain on use or
during flare-ups.
5Evaluation Considerations
- Suggested text for entry into Remarks for any
musculoskeletal DBQ - When completing any musculoskeletal DBQ,
additional information is required to comply with
a recent US Court of Appeals for Veterans Claims
(CAVC) decision in the case of Mitchell v.
Shinseki, relating to functional limitations. In
the section of the DBQ titled Functional loss
and additional limitation in ROM, additional
questions must be addressed. For each joint
examined, please provide an opinion.
6Evaluation Considerations
- 1. Whether pain, weakness, fatigability, or
incoordination could significantly limit
functional ability during flare-ups, or when the
joint is used repeatedly over a period of time,
and - 2. Describe any such additional limitation due to
pain, weakness, fatigability or incoordination,
and if feasible, this opinion should be expressed
in terms of the degrees of additional ROM loss
due to pain on use or during flare-ups. - 3. If such opinion is not feasible, please state
and provide an explanation as to why the opinion
cannot be rendered.
7Evaluation Considerations
- The examiners should indicate if pain could
significantly limit functional ability during
flare-ups or repeated use over time. - They should express this in degrees of additional
range of motion lost.
838 CFR 4.45 Exams
- Examiners should provide history and objective
findings, as well as findings of - Less movement than normal
- More movement than normal
- Weakened movement
- Excess fatigability
- Incoordination
- Pain on movement
9Major Joints
- Shoulder
- Elbow
- Wrist
- Hip
- Knee
- Ankle
10Groups of Minor Joints
- Multiple involvements of the
- Interphalangeal, metacarpal and carpal joints of
upper extremities - Interphalangeal, metatarsal and tarsal joints of
the lower extremities - Cervical vertebrae
- Dorsal vertebrae
- Lumbar vertebrae
- Lumbosacral articulation and sacroiliac joints
(rated on disturbance of lumbar spine functions)
1138 CFR 4.59 Painful Motion
- With any form of arthritis, painful motion is an
important factor of disability. - Findings of painful, unstable, or malaligned
joints due to healed injury should be entitled to
at least the minimum compensable evaluation.
(10)
1238 CFR 4.69 Dominant Hand
- Evaluation percentages involving upper
extremities will allow for a greater evaluation
when the condition affects the major (dominant)
hand. - Only one extremity can be dominant.
- If the claimant is ambidextrous, the injured hand
will be considered dominant.
1338 CFR 4.62 Circulatory Disturbances
- Do not overlook circulatory disturbance,
especially of the lower extremity following
injury in the popliteal space. - Requires rating generally as phlebitis.
14Medical Examination Criteria
- Examiner must report based on requirements of 38
CFR 4.45 - Additional x-rays, lab work, MRI or CT scans may
be ordered - Complete range of motion studies are required
- Accurate measurement of the length of any
amputation stump is required - Scars and any additional disability due to them
should be noted. They are to be rated separately
if appropriate.
1538 CFR 4.68 Amputation Rule
- The combined evaluation for disabilities of an
extremity shall not exceed the rating for the
amputation at the elective level, were the
amputation to be performed. - Examples
1638 CFR 4.58 Arthritis Due to Strain
- When there is a lower extremity shortening or
amputation, an associated arthritis that
subsequently develops (in lower extremities,
lumbosacral joints, or lumbosacral spine) will be
service connected.
17 38 CFR 4.58 Arthritis Due to Strain
- For upper extremities, we can only consider
service connection for arthritis in joints
subject to direct strain or those actually
injured.
18 Separate Evaluations for Arthritis
of the Knee
- VAOPGCPREC 23-97
- General Counsel Opinion held that a claimant who
has arthritis and instability of the knee may be
rated separately under - DC 5003 (degenerative arthritis) and
- DC 5257 (knee instability)
19Separate Evaluations for Arthritisof the Knee
- They determined that 38 CFR 4.14 (pyramiding)
only prohibits separate evaluations of disorders
having the same disabling manifestations. - A separate rating can be assigned if there is
additional disability.
20Separate Evaluations for the Knee
- VAOPGCPREC 9-2004
- General Counsel Opining held that a veteran may
receive separate ratings for - DC 5260 Limitation of flexion and
- DC 5261 Limitation of extension
- for the same knee.
- (See also FL
04-22)
21Separate Evaluationsfor the Knee
- However,
- where joint motion is not limited,
- but there is objective evidence of pain on
motion, - only one compensable evaluation can be assigned
under either DC 5260 or DC 5261. (38 CFR 4.14)
22Separate Evaluationsfor the Knee
- Although it is permissible to assign multiple
evaluations under multiple diagnostic codes for a
single knee, always abide by the amputation rule
(38 CFR 4.68). - General Counsel Opinions are not a liberalizing
interpretation of the rating schedule, and the
provisions of 38 CFR 3.114(a) do not apply.
23Prosthetic Implants
- Temporary total evaluation for one year following
replacement of shoulder, elbow, writs, hip,
knee, or ankle joint (38 CFR 4.30) - After that, rate on residual disability
- DCs 5051 5056
- SMC may be assigned during the period of total
evaluation if the permanent use of crutches are
required
24DC 5055 Knee Replacement
- 5055 Knee replacement (prosthesis).
- Prosthetic replacement of knee joint
- For 1 year following implantation of prosthesis
-
100 - With chronic residuals consisting of severe
painful motion or weakness in the affected
extremity
60 - With intermediate degrees of residual weakness,
pain or limitation of motion rate by analogy to
diagnostic codes 5256, 5261, or 5262. - Minimum rating
30
25Prosthetic Implants
- The prosthetic implant must be a total joint
replacement to warrant entitlement to the 13
months of 100 percent evaluation under the
scheduler criteria. - Partial joint replacements only warrant a 100
percent evaluation under Paragraph 30 benefits
for convalescence.
26The Spine
- Low Back Pain (LBP), Lumbosacral Strain (LS) and
subsequently developing Herniation of a Nucleus
Pulposus (HNP) - Commonly a veteran will establish SC for LBP/LS
and will later develop HNP. The HNP can be
service connected if a progressive condition can
be established. - However, denial may be appropriate if the LS-LBP
has been long asymptomatic, and no causal
relationship can be established to the HNP.
27General Rating Formula for Diseases and Injuries
of the Spine
- Unfavorable ankylosis of the entire spine
100 - Unfavorable ankylosis of the entire thoracolumbar
spine
50 - Unfavorable ankylosis of the entire cervical
spine or, forward flexion of the thoracolumbar
spine 30 degrees or less or, favorable ankylosis
of the entire thoracolumbar spine
40 - Forward flexion of the cervical spine 15 degrees
or less or, favorable ankylosis of the entire
cervical spine
30 -
28General Rating Formula for Diseases and Injuries
of the Spine
- Forward flexion of the thoracolumbar spine
greater than 30 degrees but not greater than 60
degrees or, forward flexion of the cervical
spine greater than 15 degrees but not greater
than 30 degrees or, the combined range of motion
of the thoracolumbar spine not greater than 120
degrees or, the combined range of motion of the
cervical spine not greater than 170 degrees or,
muscle spasm or guarding severe enough to result
in an abnormal gait or abnormal spinal contour
such as scoliosis, reversed lordosis, or abnormal
kyphosis
20
29General Rating Formula for Diseases and Injuries
of the Spine
- Forward flexion of the thoracolumbar spine
greater than 60 degrees but not greater than 85
degrees or, forward flexion of the cervical
spine greater than 30 degrees but not greater
than 40 degrees or, combined range of motion of
the thoracolumbar spine greater than 120 degrees
but not greater than 235 degrees or, combined
range of motion of the cervical spine greater
than 170 degrees but not greater than 335
degrees or, muscle spasm, guarding, or localized
tenderness not resulting in abnormal gait or
abnormal spinal contour or, vertebral body
fracture with loss of 50 percent or more of the
height
10
30 General Rating Formula for the
Diseases and Injuries of the Spine
- Note (1) Evaluate any associated objective
neurologic abnormalities, including, but not
limited to, bowel or bladder impairment,
separately, under an appropriate diagnostic code.
31 Ankylosis and Limitation of Motion of the Spine
- DCs 5235 5243 are used for ankylosis or
limitation of motion of the spine - Normal Ranges of Motion of TL Spine
- Forward Flexion 0 to 90 degrees
- Extension 0 to 30 degrees
- Left Lateral Flexion 0 to 30 degrees
- Right Lateral Flexion 0 to 30 degrees
- Left Lateral Rotation 0 to 30 degrees
- Right Lateral Rotation 0 to 30 degrees
32 Intervertebral Disc Syndrome (IVDS)
- DC 5243
- IVDS results from displacement of intervertebral
disc or disc fragments. - There is usually pain and other signs symptoms.
- It may also be called slipped, herniated,
ruptured, prolapsed, bulging, or protruded disc
degenerative disc disease (DDD) sciatica
discogenic pain syndrome herniated nucleus
pulposus pinched nerve etc.
33 Intervertebral Disc Syndrome (IVDS)
- The rating criteria for IVDS was revised on
September 23, 2002 and its corresponding DC
changed to 5243 on September 26, 2003. - It can now be evaluated based on
- - periods of acute symptoms, or
- - chronic orthopedic manifestations.
- If both are present, use the method that is most
advantageous to the veteran.
34 Intervertebral Disc Syndrome(IVDS)
- 5243 Intervertebral disc syndrome Rating
- With incapacitating episodes having a total
duration of at least 6 weeks during the past 12
months 60 - With incapacitating episodes having a total
duration of at least 4 weeks but less than 6
weeks during the past 12 months
40 - With incapacitating episodes having a total
duration of at least 2 weeks but less than 4
weeks during the past 12 months
20 - With incapacitating episodes having a total
duration of at least one week but less than 2
weeks during the past 12 months
10
35 Intervertebral Disc Syndrome (IVDS)
- Note (1) For purposes of evaluations under
diagnostic code 5243, an incapacitating episode
is a period of acute signs and symptoms due to
intervertebral disc syndrome that requires bed
rest prescribed by a physician and treatment by a
physician.
36 Intervertebral Disc Syndrome
- 5243 Intervertebral disc syndrome
- Evaluate intervertebral disc syndrome
(preoperatively or postoperatively) either under
the General Rating Formula for Diseases and
Injuries of the Spine or under the Formula for
Rating Intervertebral Disc Syndrome Based on
Incapacitating Episodes, whichever method results
in the higher evaluation when all disabilities
are combined under Sec. 4.25.
37Fully Developed Claims
- Advantages of an FDC Claim
- Veteran Less time identify evidence at the
time of application - VSO Greater control
- VBA Dramatically reduces processing time of
claims less claims development needed
38FDC Tips For Success
- Submit an FDC electronically
- Provide information up front
- Provide Service Treatment
- Records (STRs) and Disability Benefit
Questionnaires (DBQs) for maximum expedition of
claim - Make sure form is complete and all check boxes
are marked correctly
39VAS Obligation
- The VA will
- Retrieve relevant records from federal facilities
- Provide medical examinations/opinions
- Keep Veteran informed
40Types of Claims For FDC Submission
41 How To Avoid Exclusion From The FDC
Program
42FDC Exclusions
- A claim is considered disqualified from the FDC
Program if - Further evidence is needed from the claimant or
an identified private medical provider - The claim requires any non-federal development
- Appeal pending and their claims file is not on
station - Claimant excludes self on application
- Claim requires a character of discharge
determination - Supplemental claims or additional evidence after
receipt of the FDC - Failure to report to a VA examination
43FDC UPDATE!
- On August 6, 2012, the President signed a
comprehensive legislative package, the Honoring
Americas Veterans and Caring for Camp Lejeune
Families Act of 2012, Public Law 112-154.
Section 506 of this Act amends 38 U.S.C. Â 5110
to allow up to a one-year retroactive effective
date for awards of disability compensation based
on fully developed ORIGINAL claims for
compensation received from August 6, 2013,
through August 5, 2015. The purpose of this
change is to provide an incentive to stakeholders
to submit fully developed claims.
44 CATEGORIZED EXCLUSIONS FOR TDVA FY 2013
TO DATE
Additional Evidence Claimant declined FDC Processing Evidence received after FDC CEST Needs Non-Federal evidence development VBA Administrative Reason
2 12 196 221 471
45Average Days To CompleteFDC Claims
FDC At Completion Not FDC At Completion
3558 7849
Average Days To Complete Average Days To Complete
112.4 184.7
46Comparison
47 New Information September 2013
FL 12-25, The Fully Developed Claim Program,
states on page seven that, should a claim require
further development of evidence from the
claimant, it must be excluded from the Fully
Developed Claim program. Therefore, in this
case, exclude the claim and send the claimant a
VA Form 21-0781. In addition, if further
development of evidence is required from a
claimant related to another special issue not
included in Special Circumstances, the claim
should also be excluded from the Fully Developed
Claim program. These special issues include,
but are not limited to herbicide exposure,
exposure to Hepatitis C, and exposure to
radiation. Send the claimant a development
letter explaining why the claim was excluded and
what evidence is needed to decide the claim.
48Thank You!!