8
Other Diagnostic Classification Systems and Rating Schedules

The Veterans’ Disability Benefits Commission asked the committee about (1) the advantages and disadvantages of adopting universal medical diagnostic codes rather than using a unique system, and (2) the advantages and disadvantages of using the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (Guides) instead of the Department of Veterans Affairs’ (VA’s) Schedule for Rating Disabilities (Rating Schedule).

ALTERNATIVE DIAGNOSTIC CLASSIFICATION CODES

As a practical matter, the question is whether the Department of Veterans Affairs (VA) should drop or supplement its set of unique diagnostic codes and adopt the diagnostic classifications used by all health-care providers, including the Veterans Health Administration (VHA). These are the International Classification of Diseases (ICD), which is maintained by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is promulgated by the American Psychiatric Association (APA).


International Classification of Diseases


The ICD was originally developed as a consistent way for nations to report mortality statistics. In 1948, the sixth revision of the ICD added causes of morbidity for the first time, based on a proposed statistical classification of diseases, injuries, and causes of death drafted by a U.S.



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A 21st Century System for Evaluating Veterans for Disability Benefits 8 Other Diagnostic Classification Systems and Rating Schedules The Veterans’ Disability Benefits Commission asked the committee about (1) the advantages and disadvantages of adopting universal medical diagnostic codes rather than using a unique system, and (2) the advantages and disadvantages of using the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (Guides) instead of the Department of Veterans Affairs’ (VA’s) Schedule for Rating Disabilities (Rating Schedule). ALTERNATIVE DIAGNOSTIC CLASSIFICATION CODES As a practical matter, the question is whether the Department of Veterans Affairs (VA) should drop or supplement its set of unique diagnostic codes and adopt the diagnostic classifications used by all health-care providers, including the Veterans Health Administration (VHA). These are the International Classification of Diseases (ICD), which is maintained by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is promulgated by the American Psychiatric Association (APA). International Classification of Diseases The ICD was originally developed as a consistent way for nations to report mortality statistics. In 1948, the sixth revision of the ICD added causes of morbidity for the first time, based on a proposed statistical classification of diseases, injuries, and causes of death drafted by a U.S.

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A 21st Century System for Evaluating Veterans for Disability Benefits committee.1 The 10th and most recent revision of the ICD was published in 1992 and is used by the United States to report mortality statistics. The 9th revision (published in 1977) is still used for clinical and reimbursement purposes. Use of the ICD The original purpose of the ICD was to provide internationally consistent statistics that would allow epidemiologic comparisons within populations over time and between populations at a given point in time. In addition, it has come to be the basis for classifying diagnostic information for clinical purposes and for health insurance billing. Several countries, including the United States, have developed clinical modifications of the ICD to make it more useful in primary care settings and for reimbursement and related purposes. In the United States, this is the ICD-9-CM, which was developed by the National Center for Health Statistics (NCHS) and adopted by the federal government for Medicare and Medicaid claims in 1988 (an ICD-10-CM has been developed but has not yet been phased into use). The ICD has a nested structure allowing users to decide on the level of detail to which they want to code diagnoses. There are four-digit and, in some cases, optional five-digit subdivisions, but users not needing such detail can use the three-digit categories. For example, the three-digit code for diabetes mellitus is 250 (Table 8-1). That three-digit code is subdivided into 10 four-digit codes. Fifth-digit subclassifications can be used with each of the four-digit codes: 0—type II controlled 1—type I controlled 2—type II uncontrolled 3—type I uncontrolled Thus, for example, the diagnostic code 250.42 indicates type II diabetes with nephropathy or other renal manifestation. To take another example, the code for chronic bronchitis is 491 (Table 8-1). At the next level of detail, there are four-digit codes for simple chronic bronchitis (491.0), mucopurulent chronic bronchitis (491.1), obstructive chronic bronchitis (491.2), other chronic bronchitis (491.8), and unspecified chronic bronchitis (491.9). Obstructive chronic bronchitis 1 This account is based on a history of the development of the ICD on the WHO website. http://www.who.int/classifications/icd/en/HistoryOfICD.pdf (accessed March 26, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits TABLE 8-1 Examples of ICD Classifications 250 Diabetes mellitus   250.0 Diabetes mellitus without mention of complication   250.1 Diabetes with ketoacidosis   250.2 Diabetes with hyperosmolarity   250.3 Diabetes with other coma   250.4 Diabetes with renal manifestations   250.5 Diabetes with ophthalmic manifestations   250.6 Diabetes with neurological manifestations   250.7 Diabetes with peripheral circulatory disorders   250.8 Diabetes with other specified manifestations   250.9 Diabetes with unspecified complications 491 Chronic bronchitis   491.0 Simple chronic bronchitis   491.1 Mucopurulent bronchitis   491.2 Obstructive chronic bronchitis     491.20 Without mention of acute exacerbation     491.21 With acute exacerbation   491.8 Other chronic bronchitis   491.9 Unspecified chronic bronchitis 717 Internal derangement of knee   717.0 Old bucket handle tear of medial meniscus   717.1 Derangement of anterior horn of medial meniscus   717.2 Derangement of posterior horn of medial meniscus   717.3 Other and unspecified derangement of medial meniscus   717.4 Derangement of lateral meniscus     717.40 Derangement of lateral meniscus, unspecified     717.41 Bucket handle tear of lateral meniscus     717.42 Derangement of anterior horn of lateral meniscus     717.43 Derangement of posterior horn of lateral meniscus     717.49 Other   717.5 Derangement of meniscus, not elsewhere classified   717.6 Loose body in knee   717.7 Chondromalacia of patella   717.8 Other internal derangement of knee     717.81 Old disruption of lateral collateral ligament     717.82 Old disruption of medial collateral ligament     717.83 Old disruption of anterior cruciate ligament     717.84 Old disruption of posterior cruciate ligament     717.85 Old disruption of other ligaments of knee     717.89 Other   717.9 Unspecified internal derangement of knee SOURCE: St. Anthony’s Publishing (2003).

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A 21st Century System for Evaluating Veterans for Disability Benefits can be classified at the five-digit level as “without mention of acute exacerbation” (491.20) or “with acute exacerbation” (491.21). Internal derangement of knee, whose three-digit code is 717, has 10 four-digit codes, and 2 of the four-digit codes each can be subdivided into several five-digit codes (Table 8-1). In 2000, WHO adopted a formal process for updating the ICD between periodic comprehensive revisions. The international collaborating centers, of which one is NCHS, propose revisions and additions to an updating and revision committee, which considers whether to include them in annual updates of the ICD. Annual revisions have been made since 1995. WHO is currently in the process of developing the ICD-11, which is due to be completed and released in 2011. International Classification of Functioning, Disability and Health The ICD is a classification of diagnoses, not of health states. It does not indicate the severity of disease or injury or the patient’s level of functioning or quality of life. Another WHO classification, the International Classification of Functioning, Disability and Health (ICF), was developed to assess the consequences of disease and injury in terms of an individual’s ability to function in his or her environment (WHO, 2001): ICF is a multipurpose classification intended for a wide range of uses in different sectors. It is a classification of health and health-related domains—domains that help us to describe changes in body function and structure, what a person with a health condition can do in a standard environment (their level of capacity), as well as what they actually do in their usual environment (their level of performance). These domains are classified from body, individual, and societal perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. In ICF, the term functioning refers to all body functions, activities, and participation, while disability is similarly an umbrella term for impairments, activity limitations, and participation restrictions. ICF also lists environmental factors that interact with all these components (WHO, 2002:2). The ICF is sophisticated conceptually but is difficult to operationalize because of its complexity (see Chapter 3). Researchers in the disability and rehabilitation fields are studying how to measure the functional domains in the ICF. At this point, it has not been adopted for use by any disability benefit programs.

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A 21st Century System for Evaluating Veterans for Disability Benefits Classification Systems of Other Disability Programs The Social Security Administration (SSA) has the largest program of cash benefits for persons with disabilities. To receive disability benefits from SSA, a person must be unable to engage in any substantial gainful activity for at least a year because of a physical or mental impairment. The substantial gainful activity concept, currently defined as earning no more than $900 a month, originally derived from the War Risk Insurance Act of 1914, which defined total disability as mental or physical impairment making it impossible for the individual “to follow any substantial gainful occupations” (Berkowitz, 1987:44). SSA uses a classification system for its disability benefits program based loosely on the ICD-9-CM. Before 1985, SSA used four-digit ICD codes. In 1985, SSA modified the classification to use three digits followed by a zero. The three digits are mostly identical with the three-digit codes in the ICD-9-CM, but SSA does not use all the ICD three-digit codes. In total, the SSA system has about 240 codes. The code for diabetes mellitus (2500) is equivalent to the one in the ICD-9-CM (250), but there are separate codes for diabetic acidosis (2760), diabetic neuropathy (3570), and diabetic retinopathy (3620). The code for chronic bronchitis (4910) is equivalent to the ICD code for simple chronic bronchitis (4910) (Table 8-1). The code for knee impairments is not the same, however. SSA uses 7160 for all dysfunctional joints (e.g., shoulder, elbow, hip) regardless of cause, equivalent to the ICD-9 CM code for other and unspecified arthropathies. SSA can manage with less than a third of the approximately 800 codes used by VA to specify the impairment in adequate detail. This is because SSA is more concerned with assessment of the functional consequences on ability to work than with specifying the impairment in great detail. SSA must by law establish that a “medically determinable” impairment exists, that is, a well-supported diagnosis, but a diagnosis or the existence of an impairment by itself (with rare exceptions such as amyotrophic lateral sclerosis [ALS] is not a determining factor in making the disability decision. If the medical findings of severity meet or equal the listings, the claimant is allowed; if not, residual functional capacity is evaluated along with occupational factors such as age, education, and work history. SSA also does not have separate codes for different severities of the same impairment, partly because it is making an all-or-nothing decision— the person is disabled or is not disabled. VA, on the other hand, is concerned with determining degree of impairment. For example, SSA has one diagnostic code for all amputations, while VA has many, depending on which limb or digit is involved and how much loss has occurred. Thus, there are five codes for loss of an arm, depending on if it was severed at the shoulder, above or below the insertion of the deltoid muscle in the upper

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A 21st Century System for Evaluating Veterans for Disability Benefits arm, or above or below the insertion of the pronator teres muscle in the forearm, and the percentage ratings for each differs depending on whether it is the dominant arm. Diagnostic and Statistical Manual of Mental Disorders The DSM is a widely used classification of mental disorders. It uses the same numbering system as the ICD, although there are minor differences in what is classified under the same code. The DSM has five axes: Axis I includes clinical disorders in 14 categories, such as anxiety, childhood, cognitive, dissociative, eating, factitious, impulse control, mood, psychotic, sexual and gender identity, sleep, somatoform, and substance-related disorders. Axis II includes mental retardation and personality disorders, such as antisocial, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid, and schizotypal personality disorders. Axis III consists of medical conditions that may be relevant to the understanding and treatment of the mental disorder. Axis IV includes psychosocial and environmental factors contributing to a disorder, such as housing problems, problems with work, bereavement, and legal problems. Axis V is the Global Assessment of Functioning (GAF), which measures psychological, social, and occupational functioning on a 100-point scale. A psychiatrist uses the DSM to choose the disorder or disorders that most closely match the symptoms and signs of the patient. Each disorder has a classification number, or diagnostic code. Each disorder has diagnostic criteria that must be present. For example, the diagnostic criteria for generalized anxiety disorder (Axis I) are Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) The person finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months; only one item is required in children): restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or the mind going blank,

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A 21st Century System for Evaluating Veterans for Disability Benefits irritability, muscle tension, and sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). The focus of the anxiety and worry is not confined to features of an Axis I disorder, such as the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder (PTSD). The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder. The DSM also contains three-and-a-half pages of narrative discussion of the diagnostic features of generalized anxiety disorder; associated features and disorders; specific culture, age, and gender features; prevalence; course; familial pattern; and differential diagnosis (APA, 2000). The DSM was developed by APA in 1952 and has been revised several times. The last major revision, DSM-IV, was published in 1994. A text revision of the DSM-IV, called DSM-IV-TR, was published in 2000. The fifth edition, DSM-V, is scheduled to be released in 2011. William Narrow, research director for APA’s DSM-V task force, briefed the committee on its development. APA is conducting a series of conferences and empirical research on criteria with longitudinal and epidemiologic datasets. Some of the suggestions from the conferences are that DSM-V should include “dimensional” assessments of mental disorders, although not abandoning the categorical system, and that there should be regrouping of disorders based on advances in understanding of mental disorders. Dimensional assessments would include the degree of severity and functional limitations of a diagnosed disorder. A possible candidate for a new diagnostic grouping—based on better understanding of causes of mental disorders—would be “stress-related and fear circuitry disorders” (Narrow, 2006).

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A 21st Century System for Evaluating Veterans for Disability Benefits VA already uses the DSM, but not the current DSM-IV-TR version, because the mental disorders section of the Rating Schedule was last updated in 1996 before the DSM-IV-TR was published. For example, according to the Rating Schedule: The nomenclature employed in this portion of the rating schedule is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). Rating agencies [i.e., raters] must be thoroughly familiar with this manual to properly implement the directives in §4.125 through §4.129 and to apply the general rating formula for mental disorders in §4.130 (38 CFR 4.130). VA also organizes the schedule of ratings for mental disorders under eight broad categories that correspond to DSM categories, such as schizophrenia and other psychotic behaviors, mood disorders, and somatoform disorders. Some major DSM categories are not used, for example, disorders usually first diagnosed in infancy, childhood, or adolescence (e.g., mental retardation, attention deficit/hyperactivity disorder [ADHD]), substance-related disorders, and personality disorders. Individuals with disabling childhood disorders presumably are not accepted for military service. For policy reasons, substance abuse and personality disorders are expressly barred from being the basis for disability compensation. Within major categories of mental disorders, VA does not use all the specific disorders that have DSM codes. For example, instead of listing the six specific adjustment disorders (e.g., with depressed mood, with anxiety) in the DSM and allowing each to be acute or chronic, VA uses a single code, called chronic adjustment disorder. In other cases, VA uses some of the specific disorders but not others. Under mood disorders, for example, VA combines seven bipolar diagnoses into one and does not include substance-induced mood disorder, and there is one category for “mood disorder, not otherwise specified (NOS),” instead of separate NOS diagnoses for depressive disorders and for bipolar disorders. In sum, VA has adapted the DSM classification system to its needs by choosing a three-digit disorder (i.e., adjustment disorders), using some but not all other disorders at the four- and five-digit level, and/or combining diagnoses (e.g., making three DSM diagnoses for dissociative disorders into one—“dissociative amnesia, dissociative fugue, and dissociative identity disorder”). The effect is to simplify categories (VA uses 36 diagnostic codes whereas the DSM uses more than 300), focus the Rating Schedule on diagnoses more common among veterans (e.g., depression, PTSD, schizophrenia), and exclude diagnoses that do not apply (e.g., mental retardation). VA also uses the GAF, Axis V of the DSM. It is not mentioned in the Rating Schedule, but VA materials for training rating veterans service

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A 21st Century System for Evaluating Veterans for Disability Benefits representatives say that Compensation and Pension (C&P) Services mental examinations must include the DSM-IV multiaxial format, including the GAF. Raters are instructed to use the GAF score as one, although not the sole or main, basis for evaluating mental disability. The C&P examination worksheet calls for the current GAF score, and VHA examiners conducting mental examinations must be trained in use of the GAF. THE AMA GUIDES: AN ALTERNATIVE RATING SCHEDULE? In the 1950s, AMA began to issue a series of guides to the evaluation of permanent impairment for use by physicians asked to assess patients seeking disability insurance or workers’ compensation benefits. In 1971, they were combined in one volume, called Guides to the Evaluation of Permanent Impairment. The current fifth edition of the Guides was issued in 2000. It defines impairment to be “a loss, loss of use, or derangement of any body part, organ system, or organ function” (AMA, 2001:2). A permanent impairment is one that has reached “maximal medical improvement,” meaning it is unlikely to improve substantially for the next year. Disability is defined by the Guides as “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment,” and it notes that “an impaired individual may or may not have a disability” (AMA, 2001:3). The role of the physician, the Guides makes clear, is limited only to determining degree of medical impairment and individual-level functional limitations on activities, and to providing supporting medical information to those making disability determinations, not deciding if someone is disabled for purposes of disability benefits. The Guides is organized into chapters on body systems. Some chapters focus on anatomic loss, and others on functional loss, “depending upon common practice in that specialty” (AMA, 2001:4). The example given of anatomic loss is an enlarged heart. The corresponding functional loss is the loss in the heart’s ability to pump blood, as measured by the ejection fraction.2 The criteria for evaluating degree of impairment are based on the degree to which the impairment reduces the individual’s ability to engage in activities of daily living, “excluding work” (emphasis in the original). The ratings are designed to reflect functional limitations, not degree of disability (AMA, 2001:4). This is because the determination of disability involves more than evaluation of impairment. It also involves information about the individual’s education, skills, job history, age, and environmental circumstances, which are not matters that physicians are trained or equipped to 2 The ejection fraction is the percentage of blood that is pumped from a filled heart ventricle with each heartbeat.

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A 21st Century System for Evaluating Veterans for Disability Benefits assess (AMA, 2001). Although the Guides says that activities of daily living (ADLs) are part of the impairment rating process, most of the chapters in the fifth edition are based on anatomic losses and limitations. Robert Rondinelli, lead medical editor of the sixth edition of the Guides, which is due to be completed in late 2007, briefed the committee on plans for the sixth edition (Rondinelli, 2006). He told the committee that this next edition will be revised in accordance with the concepts and nomenclature of the ICF, meaning distinguish between impairment of body functions and structures, activity limitations, and participation restrictions; clarify that an impairment rating based on the Guides is “a consensus-derived percentage estimate of loss of activity, which reflects severity of impairment for a given health condition, and the degree of associated loss of activities of daily living,” but not a direct estimate of work disability; be as evidence-based as possible, but otherwise be based on expert consensus; incorporate as much functional assessment as possible, including assessment of ADLs, to supplement anatomic measures; and adopt, if possible, an ADL scale for use in applying the Guides (in the absence of an agreed-on scale appropriate for a working population, the fifth edition listed commonly used validated scales and left it to the physician to choose the most appropriate one). FINDINGS AND CONCLUSIONS Diagnostic Classification Systems The Rating Schedule has been in use since 1945. It includes almost 800 unique diagnostic codes categorized by body system. Raters match the medical conditions of veterans applying for disability compensation with one or more of the codes and then use the criteria associated with each code to assign a percentage rating. Therefore, it is important that the diagnostic categories represented by the diagnostic codes in the Rating Schedule be as medically correct as possible or else the criteria used for determining the rating will not be appropriate. Numerical codes first appeared in the 1933 Rating Schedule and were continued in 1945, when the current Rating Schedule was promulgated. They are unique to VA. According to VA, the codes “are arbitrary numbers for the purpose of showing the basis of the evaluation assigned and for statistical analysis in the VA” (38 CFR § 4.27). VA has periodically updated diagnostic codes within the Rating Schedule to reflect changes in medical nomenclature and to add new diseases

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A 21st Century System for Evaluating Veterans for Disability Benefits (e.g., HIV and chronic fatigue syndrome). Many of the body systems were comprehensively revised in the early to mid 1990s, when many, if not all, diagnostic codes were revised, including infectious diseases/immune disorders/nutritional deficiencies, respiratory, cardiovascular, genitourinary, gynecological, hemic/lymphatic, endocrine, mental, dental/oral, and the muscles part of cardiovascular. The skin system was overhauled in 2001. In most of these cases, 90 to 100 percent of the diagnostic codes were changed in some way, ranging from updating the name to redefining what the code covers to changing the rating criteria. Some body systems have not been comprehensively revised, namely, the orthopedic part of musculoskeletal, neurological, and digestive systems. In all, as shown in Table 4-1 in Chapter 4, 35 percent (281 of 798) of the codes have not changed since 1945, most of them in the musculoskeletal (105), neurological (105), and digestive systems (20). As a result, there are areas in which conditions are misclassified in comparison with current medical standards. For example, multiple sclerosis and myasthenia gravis are categorized as neurodegenerative diseases in the Rating Schedule, but are currently thought of as autoimmune diseases. Multiple sclerosis is not necessarily degenerative; it is known to have several forms, including a relapsing-remitting, secondary progressive, and primary progressive type, each with a different course and impact on function. The subcategorization of epilepsy is out of date. There are pros and cons to changing the diagnostic classification system to the ICD. The strongest arguments for adopting the ICD are that it would (1) use the categories of diagnoses, definitions of what fits those categories, and nomenclature used in current medical practice and make the exchange of information between the examiners and raters more effective in identifying a veteran’s medical problems, and (2) facilitate better understanding of trends in the health of the veteran population. The strongest arguments against adopting the ICD are (1) the costs involved and (2) loss of the role the current diagnostic criteria play in identifying the location and degree of injury in great detail for rating purposes. Veterans are diagnosed, treated, and rehabilitated in a health-care system in which the ICD and the DSM are the bases of common language and understanding. The VA disability compensation system relies heavily on medical records, which are expressed in terms of ICD and DSM categories and terms. Raters use these records, whether from private providers or the VHA health-care system, as part of establishing the diagnosis or diagnoses pertinent to a veteran’s claim. C&P examinations, whether by VHA clinicians or contract clinicians, play a prominent role in the disability compensation system, probably in part because the examiner provides the service of interpreting the medical information and translating it into Rating Schedule terms for raters to use. This may mean that more prominence than warranted is given to the C&P examiner’s snapshot evaluation

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A 21st Century System for Evaluating Veterans for Disability Benefits of a veteran than to the longitudinal information found in the treating physician’s records. Having the same diagnostic categories for the disability compensation program as VHA and other health-care providers would facilitate communication and understanding of a veteran’s health problems. The rater would be better able to relate information in medical records to the Rating Schedule if the diagnostic categories corresponded. It would also help the program keep up with advances in medical understanding, because the ICD and the DSM undergo regular revision and periodic comprehensive revisions. This would help avoid situations in which some currently identified conditions are not found in the Rating Schedule. Raters probably realize that paralysis agitans is called Parkinson’s disease and that dementia of the Alzheimer’s type is called Alzheimer’s disease, but they would have to determine which codes to use for veterans who are diagnosed with multiple system atrophy, corticobasal degeneration, or progressive supranuclear palsy. Also, closely-related diseases such as progressive muscular atrophy, bulbar palsy, and ALS are grouped together in the ICD as motor neuron disease (although they have different five-digit codes), but they are separated in the Rating Schedule, and one, bulbar palsy, has different rating criteria than the other two. The Rating Schedule contains a number of instances of outdated terms and names, especially in the orthopedic section of the musculoskeletal and neurological systems, which have not been comprehensively updated since 1945. Raters must match conditions in the medical records to the proper diagnostic code in the Rating Schedule. Knowing that Parkinson’s disease should be rated under paralysis agitans has already been mentioned. Similarly, raters have to know that veterans presenting with an unstable shoulder or elbow should be evaluated under one of the codes in the Rating Schedule for “flail joint,” because it is an obsolete term unlikely to appear in their medical treatment records. As noted in Chapter 2, traumatic brain injury is the signature injury of the war in Iraq. The Rating Schedule has a diagnostic code for brain disease due to trauma (8045), which was last revised in 1961 (VA, 2006). The rater is directed to evaluate the condition according to its various neurological consequences, “such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc.” There is no other guidance in the Rating Schedule on the likely sequelae of brain injury for the rater to consider. In recent years, for example, with better measures and definitions, medical researchers have discovered significant neurobehavioral impacts of mild to moderate brain trauma. Each condition that is service connected and rated is given a hyphenated code with 8045 as a prefix (before the hyphen) and the diagnostic code for the related condition as the suffix (after the hyphen). This permits tracking the number of veterans being compensated for traumatic

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A 21st Century System for Evaluating Veterans for Disability Benefits brain injury; however, this is not possible for spinal cord injury, which has no diagnostic code, but is rated only on the basis of the nerves that no longer work and on the impact on organ function. Another advantage of using ICD codes would be the reduction in the rate of analogous codes. No classification system can identify every possible diagnosis ahead of time, not even one with 800 codes such as those found in the VA Rating Schedule. VA provides flexibility by allowing the rater to use an analogous condition as a guide for determining the rating percentage. The first two numbers are those of the relevant body system, the second two numbers are 99, and the four-digit number following the hyphen is for the analogous condition being used for rating purposes. At the end of FY 2005, 9 percent (370,000) of the 7.7 million service-connected disabilities had analogous codes (Figure 8-1). These percentages were higher for some body systems, especially dental/oral (25 percent), genitourinary (18 percent), and hemic/lymphatic (16 percent). The rate of use for musculoskeletal conditions is 12 percent, but analogous codes are concentrated in the orthopedic part of musculoskeletal, where they constituted 15 percent of the codes. Analogous codes could be analyzed to identify impairments that occur often enough to deserve their own code or for which the criteria in existing codes are not adequate. The Army has cited Crohn’s disease as an example of the latter (U.S. Army, 2007). There is no diagnostic code for Crohn’s, so it must be rated by analogy. Raters may choose to use the criteria for ulcerative colitis (7323) or irritable colon syndrome (7319) to rate the claimed condition, depending on the symptomatology. Code 7319 allows ratings for abdominal distress up to 30 percent, while 7323 allows ratings up to 100 percent in more severe cases. The use of multiple codes makes it difficult to track the number of Crohn’s disease claims, compare the incidence of Crohn’s with other populations, or recognize when the number of cases of Crohn’s would justify establishment of a diagnostic code to make rating more uniform and efficient. Use of DSM categories illustrates the potential effect of using a universal code. The categories are designed to be comprehensive and mutually exclusive. This is probably the reason that the rate of analogous codes for mental ratings was less than 1 percent, the lowest rate of all the body systems. Use of common diagnostic categories would also allow VA managers and researchers to compare populations and trends that would help in program planning and in epidemiologic and health services research. VA’s diagnostic codes are unique and do not allow comparisons of trends in disabilities in populations served by VHA or the Department of Defense (DoD) or research normed to the veteran population. Lack of ICD codes makes it difficult to project actuarial trends or to identify emerging trends, such as Gulf War illnesses. Tracking trends in the ailments of veterans who served

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 8-1 Rate of use of analogous codes by body system, FY 2005.All NOTE: Rate is the number of service-connected disabilities coded as analogous (XX99) divided by the number of all service-connected disabilities in each body system. SOURCE: IOM (2007). in a particular war and comparing them with other veterans or the general population would help VA identify health-care needs and be part of the surveillance system for recognizing conditions that should be presumptively service connected. Tracking trends in the disabling conditions of veterans in particular military occupational specialties could help VA identify occupational health problems for DoD to address. Switching to ICD codes would have some downsides. The short-term direct costs would be significant in terms of changing computer systems and retraining raters. These costs would already be incurred, however, if the Rating Schedule undergoes a comprehensive revision in which most of the codes would be changed anyway. The costs of switching to a different set of codes would also be offset by the benefits for veterans of having a system aligned with modern medical practice and record keeping. In addition, the switch does not have to be sudden. Raters could continue to use the current codes while phasing in ICD codes.

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A 21st Century System for Evaluating Veterans for Disability Benefits Another downside would be changing the way the current codes are used to specify the degree of loss of a particular body structure or system. For example, there are different codes for different degrees of amputation of an arm or leg or various combinations of amputated fingers and toes. However, there is nothing inherent to the ICD that prevents achieving this purpose because of the way the numbering can be nested. The ICD-9-CM code for traumatic amputation of leg(s) is 897, but there are fourth-digit modifiers for the height of the amputation on the leg. ICD users may pick their own set of codes, perhaps at the three-digit level for some conditions, and at the four- or five-digit level for others, as VA has done with the DSM-IV. VA could add modifiers when subcategories not needed in regular medical practice are desired for its own purposes. Recommendation 8-1. VA should adopt a new classification system using the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) codes. This system should apply to all applications, including those that are denied. During the transition to ICD and DSM codes, VA can continue to use its own diagnostic codes, and subsequently track and analyze them comparatively for trends affecting veterans and for program planning purposes. Knowledge of an applicant’s ICD or DSM codes should help raters, especially with the task of properly categorizing conditions. VA should use the most recent versions of the ICD and the DSM in the disability determination process. When the Rating Schedule is revised, it should include the conditions most prevalent in the veteran population, classified according to current medical concepts and terminology. Then each should be given the relevant ICD or DSM code, probably at the three-digit level, which would be a relatively small subset of ICD codes. AMA Guides Impairment Rating System Use of the AMA Guides would have some advantages. As with the ICD and the DSM, it undergoes comprehensive updating on a periodic basis and, at this point, it is medically more up to date than the Rating Schedule. If VA is going to revamp the Rating Schedule to align with current medical knowledge, as recommended in Chapter 4, it might consider adopting the already proven, more up-to-date Guides, or adopt it for certain body systems. It should be noted, however, that the Guides was designed for use in a different disability decision system than VA’s (that is, workers’ compensation), which has a different division of labor between the medical examiner and the disability decision maker. In workers’ compensation, the physician is asked to evaluate the claimant and determine a percentage

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A 21st Century System for Evaluating Veterans for Disability Benefits rating of total impairment. The Guides leaves it to the adjudicator in the workers’ compensation program or other disability program to determine degree of disability, which involves considerations of functioning that the Guides does not address. The Guides was designed for use by a licensed physician and limited to a physician’s areas of competence, meaning evaluation of impairment of body structures and functions and of the ability of the individual to carry out basic daily activities of self-care, such as bathing, dressing, toileting, getting in or out of a chair or bed, and eating, and to live independently, such as making meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.3 According to the Guides, physicians have the discretion to provide an assessment of an individual’s work-related disability only if they are knowledgeable about the essential requirements of a specific job and work environment. Evaluation of an individual’s ability to return to work in general, such as to any job in the person’s field, is a different matter: A decision of this scope usually requires input from medical and nonmedical experts, such as vocational specialists, and the evaluation of both stable and changing factors, such as the person’s education, skills, and motivation, the state of the job market, and local economic considerations (AMA, 2001:14). The Guides includes an example of individuals with the same degree of clinical impairment (e.g., 30 percent because of pericardial heart disease) but very different degrees of disability, depending on whether their job is sedentary or involves manual labor (AMA, 2001). The Guides is organized by body system but uses a broad numbering system. The cardiovascular system, for example, has four categories: 4.1, hypertensive cardiovascular disease; 4.2, diseases of the aorta; 4.3, vascular disease affecting the extremities; and 4.4, diseases of the pulmonary arteries. The neurological system has more categories—eight—and some are subdivided. The criteria for rating cranial nerves (13.4), for example, are discussed under subheadings for the olfactory nerve, 13.4a; optic nerve, 13.4b; oculomotor, trochlear, and abducens nerves, 13.4c; and so on, through the hypoglossal nerve, 13.4i. Diagnostic codes are not used in the Guides. It is left to the physician examiner to know which criteria to use for which diagnosis. For instance, the section on criteria for rating cerebral impairments mentions some conditions in examples, such as traumatic brain injury, Parkinson’s disease, uremic encephalopathy, epilepsy, 3 These correspond to activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (AMA, 2001). For definitions of ADLs and IADLs, see NCHS (2007a,b).

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A 21st Century System for Evaluating Veterans for Disability Benefits and dysphasia, but many others, such as multiple sclerosis and ALS, are not mentioned. The Guides, designed to measure degree of permanent impairment and not degree of ability to work (which is to be determined by government agencies or insurance companies), tends to have lower ratings than the Rating Schedule. An example in the Guides is upper extremity amputation (Table 8-2). The AMA Guides rates amputation of a leg at the hip at 40 percent (whole person) and the Rating Schedule rates it at 90 percent4. Similarly, an individual with severe loss of hearing in both ears would receive a rating of 50 percent from the Rating Schedule and 34 percent from the Guides.5 Total loss of hearing is rated 100 percent in the Rating Schedule and 35 percent in the Guides. For diabetes mellitus, the AMA Guides allows ratings of 0 to 5 percent and 6 to 10 percent for type 2 diabetes, the higher rating if control of plasma glucose requires both a restricted diet and medication (oral agent or insulin) and there is evidence of micro-angiopathy (retinopathy or albuminaria of greater than 30 mg/dL). The Guides allows 11 to 20 percent for type 1 diabetes and 21 to 40 percent if there is frequent hyper- or hypoglycemia despite conscientious efforts to control plasma glucose levels by the individual and his or her physician. Secondary manifestations of type 1 or 2 diabetes (e.g., retinopathy, nephropathy, neuropathy, atherosclerosis) are rated separately. The Rating Schedule provides percentages from 10 to 100 percent for diabetes mellitus, with the 100 percent rating requiring: (1) more than one daily injection of insulin, (2) restricted diet, and (3) activity restrictions with (4) episodes of ketoacidosis or hypoglycemic reactions requiring (a) at least three hospitalizations annually or (b) weekly visits to a diabetic care provider, plus (5) either progressive loss of weight and strength or complications that would be compensable if separately evaluated. As in the Guides, secondary manifestations are rated separately. The Guides does not determine percentage of impairment from mental disorders. According to the fifth edition: Unlike cases with some organ systems, there are no precise measures of impairment in mental disorders. The use of percentages implies a certainty 4 The AMA Guides rates impairment for specific body parts and then translates that rating into a whole person rating. For example, a 100 percent amputation of the leg at the hip translates into a 40 percent whole person rating. 5 This assumes a pure-tone average (PTA) of 90 decibels hearing loss at the four frequencies used to calculate the PTA. In the VA Rating Schedule, the four frequencies are 1,000, 2,000, 3,000, and 4,000 Hertz. For the Guides, the four frequencies are 500, 1,000, 2,000, and 3,000 Hertz. Because noise-induced hearing loss primarily affects the frequencies of 3,000, 4,000, and 6,000 Hertz, both of these methods underestimate the extent of the acquired hearing loss, although the Rating Schedule more accurately reflects the effects of noise-induced hearing loss than the Guides.

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A 21st Century System for Evaluating Veterans for Disability Benefits TABLE 8-2 Comparative Impairment Ratings for Upper Limb Amputation   VA Rating Schedule AMA Guides Amputation Level Dominant Hand Nondominant Hand Upper Extremity Whole Person Shoulder disarticulation 90 90 100 60 Arm above deltoid insertion 90 80 100 60 Arm below deltoid insertion 80 70 95 57 Forearm above pronator teres (VA)/bicipital insertion (AMA) 80 70 95 57 Forearm below pronator teres (VA)/bicipital insertion (AMA) 70 60 94–90 56–54 Wrist 70 60     All digits 70 60 90 54 NOTE: The insertion points for the pronator teres and bicipital muscles are at slightly different points on the upper forearm, so it is possible for someone to have an amputation above the pronator teres and below the bicipital insertion, which is just below the elbow. SOURCES: VA Schedule for Rating Disabilities (diagnostic codes 5120–5125) and AMA Guides (Table 16–4). that does not exist. Percentages are likely to be used inflexibly by adjudicators, who then are less likely to take into account the many factors that influence mental and behavioral impairment. In addition, the authors are unaware of data that show the reliability of the impairment percentages (AMA, 2001:361). Instead, the Guides asks examiners to rate four domains of behavior using a five-category scale ranging from 1 (no impairment noted) to 5 (extreme impairment). The dimensions are ADLs; social functioning; concentration, persistence, and pace; and adaptation to stressful situations in complex or worklike settings (tendency to decompensate). Thus an individual might be assigned a 3 on social function, a 5 on concentration, a 1 on ADLs, and a 4–5 on adaptation (as was done in an example of an individual with a major depressive episode and associated anxiety after recovering from a heart attack). It would then be up to the adjudicator to determine a percentage of disability based on all the informa-

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A 21st Century System for Evaluating Veterans for Disability Benefits tion in the veteran’s medical record, including the four mental assessments with supporting rationales. In sum, there are both advantages and disadvantages to adopting the AMA Guides. The advantages are that it is more up to date medically, and (or because) it is updated on a regular basis. The disadvantages are that it is designed to be used by licensed physicians; measures and rates impairment and, to some extent, daily functioning, but not disability or quality of life; and does not provide mental ratings. The sixth edition is expected to improve the evidence base for impairment evaluation and include more assessment of ADLs, but it still will not be intended for use as a tool for evaluating ability to work. Recommendation 8-2. Considering some of the unique conditions relevant for disability following military activities, it would be preferable for VA to update and improve the Rating Schedule on a regular basis rather than adopt an impairment schedule developed for other purposes. VA should update its Rating Schedule and improve it to the extent possible by including validated functional limitations measures. The evaluation procedures and severity criteria found in the AMA Guides, but not in the Rating Schedule, could be adopted for certain conditions, as does Social Security, for example, by requiring use of the techniques in the AMA Guides for measuring joint motion. REFERENCES AMA (American Medical Association). 2001. Guides to the evaluation of permanent impairment, 5th Edition. Chicago, IL: AMA. APA (American Psychiatric Association). 2000. Diagnostic and statistical manual of mental disorders, 4th Edition. Text Revision (DSM-IV-TR). Washington, DC: APA. Berkowitz, M. 1987. Disabled policy–America’s programs for the handicapped. New York: Cambridge University Press. IOM. 2007. IOM staff analysis of data in VA statistical report, RCS 20-0227, “Diagnoses counts grouped by percentage, service-connected compensaton only, all periods [of service], as of September 30, 2005.” Report prepared by VBA/D&IS, December 27, 2005, and provided to IOM. Narrow, W. E. 2006. APA’s work toward DSM-V. Presentation to the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, Washington, DC, September 21. NCHS (National Center for Health Statistics). 2007a. Instrumental activities of daily living (IADLs). http://www.cdc.gov/nchs/datawh/nchsdefs/iadl.htm (accessed March 26, 2007). NCHS. 2007b. Activities of daily living (ADLs). http://www.cdc.gov/nchs/datawh/nchsdefs/ADL.htm (accessed March 26, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits Rondinelli, R. D. 2006. AMA guides 6th ed: Applications to compensation and pensioning within the Veterans Benefits Administration. Presentation to the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, Washington, DC, September 21. St. Anthony’s Publishing. 2003. Professional ICD-9-CM Code Book 2001, 6th Edition, Vols.1, 2, and 3. Reston, VA: St. Anthony’s Publishing. U.S. Army. 2007. Department of the Army Inspector General inspection of the physical disability evaluation system. Washington, DC: Office of the Inspector General, Department of the Army, March 6. http://www.army.mil/institution/operations/reports/IGReport-APDESI/IG%20Report%20-%20Army%20Physical%20Disability%20Evaluation%20System%20Inspection.pdf (accessed March 15, 2007). VA. 2006. Veterans Benefits Administration program guide 21.2, Part II, index to transmittal sheets for compensation and pension regulations, 38 CFR Part 4. Washington, DC: Veterans Benefits Administration, VA. http://www.warms.vba.va.gov/admin21/guide/pg21_2/part4.doc (accessed August 7, 2006). WHO (World Health Organization). 2001. International classification of functioning, disability and health: ICF. Geneva: WHO. WHO. 2002. Towards a common language for functioning, disability and health: ICF. Geneva: WHO. http://www3.who.int/icf/beginners/bg.pdf (accessed March 25, 2007).