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Orthopedic Rating Principles

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In this lesson, the students will achieve understanding of the basic principles for applying the Rating Schedule in evaluating musculoskeletal disabilities. – PowerPoint PPT presentation

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Title: Orthopedic Rating Principles


1
Orthopedic Rating Principles
TDVA Annual Training
October 2013
2
TDVA Annual Training
  • Training will focus on the evaluations of knee
    disabilities (including replacements) and spine
    disabilities.

3
Evaluation 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.

4
Evaluation 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.

5
Evaluation 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.

6
Evaluation 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.

7
Evaluation 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.

8
38 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

9
Major Joints
  • Shoulder
  • Elbow
  • Wrist
  • Hip
  • Knee
  • Ankle

10
Groups 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)

11
38 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)

12
38 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.

13
38 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.

14
Medical 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.

15
38 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

16
38 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)

19
Separate 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.

20
Separate 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)

21
Separate 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)

22
Separate 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.

23
Prosthetic 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

24
DC 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

25
Prosthetic 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.

26
The 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.

27
General 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

28
General 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

29
General 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.

37
Fully 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

38
FDC 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

39
VAS Obligation
  • The VA will
  • Retrieve relevant records from federal facilities
  • Provide medical examinations/opinions
  • Keep Veteran informed

40
Types of Claims For FDC Submission
41
How To Avoid Exclusion From The FDC
Program
42
FDC 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

43
FDC 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.  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
45
Average 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
46
Comparison
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.
48
Thank You!!
  • Questions????
  • THE END!
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