Proposed Changes to the Ears, Nose & Throat
Proposed Changes to the Ears, Nose & Throat
On February 15th, 2022, the VA published proposed changes to the ratings of Ears, Nose, and Throat.
These were published along with changes to the entire Respiratory System, which we are currently writing up and will post about shortly.
The current VASRD does not include an Ears, Nose, and Throat section. Instead, the Ears have their own section, and the Nose and Throat are included in the Respiratory section. The VA proposes to combine these conditions together into their own section since they are associated together in modern medicine.
The following are the VA’s new proposed changes to the ratings for the Ears, Nose, and Throat. The changes are fairly extensive, so we’ll walk through each, one at a time.
For each condition, the small, indented parts are the codes as they are right now. After the current code, we’ll discuss the proposed changes and the VA’s justification.
COMMENTING IS CLOSED:
NOTE: As of September 23, 2022 no actual change date has not been published. Once the VA has finalized the proposed changes, there will be 60 days before any changes actually take effect. Check here at this website for any updates.
VA target date of April 2024 for final rule publication.
Proposed Changes to the Ratings of the Ears, Nose, and Throat
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Note on Nose and Throat Conditions
The VA currently includes conditions of the nose and throat in the Respiratory System section of the VASRD.
They are proposing to move the codes for nose and throat conditions from the Respiratory System section to the Ear section of the VASRD, creating an Ear, Nose, and Throat section.
The ear, nose, and throat (ENT) are commonly treated together in the medical community, and this change would align the VASRD with that standard.
Just be aware that in the following discussion of the proposed changes, you’ll see the code numbers for nose and throat conditions change because of this move.
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The Hearing Loss Rating System
The VA isn’t changing the hearing loss ratings at all, but is proposing to update some of the terminology and clarify vague principles already being used. Here are the most important changes:
1. Instead of “speech discrimination test,” the VA proposes changing it to “word recognition test,” a more commonly-used term.
2. VA proposes to clarify that the puretone audiometry test used for rating purposes is the air conduction test, not the bone conduction test used only for diagnosis.
3. In regards to the word recognition test, it is not to be used when there are language difficulties, inconsistent scores, etc. The VA proposes to further clarify that the “language difficulties” particularly applies to veterans who are not fully fluent in English. They also propose to add that this test is not to be used for veterans with cognitive impairments that interfere with their ability to process language, since a large population of veterans have TBIs and other conditions that result in cognitive language impairments.
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-Current- Code 6100: Hearing loss that is not caused by another condition is rated under this code. This condition is rated based on the hearing loss rating system.
-Proposed- Code 6100: Hearing loss that is not caused by another condition is rated under this code. This condition is rated based on the hearing loss rating system.
If tinnitus (the ringing sound in the ear that often comes after exposure to serious aural trauma like explosions) is present along with the hearing loss, the minimum rating is 10%.
The only proposed change to this code is to include a provision for a minimum 10% rating if tinnitus is present.
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The only proposed change to code 6200 for chronic suppurative otitis media is to remove tinnitus as a separate rating option since it will be covered by the hearing loss rating.
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Code 6201 for chronic nonsuppurative otitis media with effusion will not change.
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-Current- Code 6202: Otosclerosis is an abnormal growth of bone in the middle ear. This condition is rated based on the hearing loss rating system.
-Proposed- Code 6202: Otosclerosis is an abnormal growth of bone in the middle ear. This condition, including any remaining symptoms after a stapedectomy or stapedotomy is performed, is rated based on the hearing loss rating system.
The only proposed change to this code is to clarify that post-surgical residuals are also covered under this code.
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-Current- Code 6204: Peripheral vestibular disorders are conditions that affect the ears’ ability to sense proper body balance. Symptoms include dizziness, sense of being in motion or spinning, wooziness, or motion sickness. Before a condition can be rated under this code, definite evidence of the exact condition and a firm diagnosis must be made. A sense of being off-balance on its own is not ratable. If the diagnosed condition also causes hearing loss or liquid coming out the ear, then those symptoms can be rated in addition to a rating under this code.
If there is dizziness that occasionally causes staggering when walking, it is rated 30%. If there is occasional dizziness, it is rated 10%.
-Proposed- Code 6204: Peripheral vestibular disorders are conditions that affect the ears’ ability to sense proper body balance. It can affect one or both ears. Symptoms include dizziness, sense of being in motion or spinning, wooziness, or motion sickness.
Before a condition can be rated under this code, definite evidence of the exact condition and a firm diagnosis must be made. A sense of being off-balance on its own is not ratable. If the diagnosed condition also causes hearing loss or liquid coming out the ear, then those symptoms can be rated in addition to a rating under this code.
This condition is rated on how it affects your ability to work and perform self-care activities, including dressing, bathing/hygiene, eating, moving around, and getting from place to place. All limitations must be noted by your doctor in your medical records.
A 100% rating is given if the condition causes symptoms during the past 6 months that have made it impossible to work and/or perform self-care activities without daily assistance from another person.
A 30% rating is given if the condition causes symptoms during the past 6 months that require regular effort and modifications or accommodations to accomplish work and/or self-care activities without assistance.
A 10% rating is given if the condition causes symptoms during the past 6 months that require occasional modifications, but do not interfere significantly with work and/or self-care activities.
The VA is proposing significant changes to this code. The current rating system only considers dizziness and staggering, but peripheral vestibular disorders can cause a wide-range of symptoms that can significantly affect all aspects of work and self-care. These changes will rate all symptoms based on how they affect work and self-care. They also add a 100% rating level for conditions so severe that it’s impossible to work or take care of yourself on your own.
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-Current- Code 6205: Meniere’s syndrome (endolymphatic hydrops) is a disorder of the inner ear that affects both hearing and balance. Symptoms include hearing loss, tinnitus, and dizziness or wooziness. This condition can be rated one of two ways: once under this code, or three ratings, one under tinnitus, one under hearing loss, and one as a peripheral vestibular disorder, can be combined. Choose the rating option that gives the higher rating.
If there is hearing loss with episodes of dizziness and staggering while walking that occur more than once a week, whether or not there is tinnitus, it is rated 100%. If there is hearing loss with episodes of dizziness and staggering while walking that occur one to four times a month, whether or not there is tinnitus, it is rated 60%. If there is hearing loss with episodes of dizziness less than once a month, whether or not there is tinnitus, it is rated 30%.
-Proposed- Code 6205: Meniere’s syndrome (endolymphatic hydrops) is a disorder of the inner ear that affects both hearing and balance. Symptoms include hearing loss, tinnitus, and dizziness or wooziness. This condition can be rated one of two ways: once under this code, or once for hearing loss and once as a peripheral vestibular disorder. Choose the rating option that gives the higher combined rating.
In order to qualify to be rated under this code, Meniere’s must be officially diagnosed by an otolaryngologist or neurologist.
A 100% rating is given if there is hearing loss (with or without tinnitus) and either episodes of dizziness five or more times each month during the past 6 months or continually feeling unbalanced and staggering while walking.
A 60% rating is given if there is hearing loss (with or without tinnitus) and episodes of dizziness one to four times each month during the past 6 months.
A 30% rating is given if there is hearing loss (with or without tinnitus) and episodes of dizziness less than once a month during the past 6 months.
The VA isn’t proposing many changes to this code. The ratings are staying essentially the same, although the proposed changes make the requirements more specific to ensure correct rating application. They are also removing tinnitus as a separate rating option since it will be covered under the hearing loss rating or a rating under this code.
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Codes 6207 (loss of auricle), 6208 (malignant tumors), 6209 (benign tumors), 6210 (chronic otitis externa), and 6211 (ear drum tear) will not change.
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The VA proposes to remove code 6260 for tinnitus since tinnitus is not a condition in and of itself but is a symptom of another condition. As such, the VA is proposing changes to the ratings of conditions that commonly cause tinnitus in order to cover tinnitus under those ratings. Anyone currently rated under this code will continue to receive their 10% rating.
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The ratings for code 6502, deviation of the nasal septum, will not change, but the code number will change to 6220.
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-Current- Code 6504: Loss of part of the nose or significant scarring is rated 30% if both nasal passages are exposed or 10% if there is an obvious disfigurement. It can either be rated under this code or under code 7800 for disfigurement if it would give a higher rating.
-Proposed- Code 6221: Loss of part of the nose or significant scarring of the nose is rated under this code. The degree of injury and the ability to wear a prothesis must be documented by a qualified specialist.
A 30% is given if half or more is missing and a prosthesis cannot be used.
A 20% is given if less than half is missing and a prosthesis cannot be used.
A 10% is given for any loss of the nose where a prosthesis can be used.
A 0% is given if a prosthesis is not required or recommended.
The condition can either be rated under this code or under code 7800 for disfigurement if it would give a higher rating.
The VA is proposing to change the ratings for this condition to better reflect the work and social impact of the condition based on the actual loss/disfigurement and the ability to wear a prosthesis.
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-Current- Sinusitis Rating System
Sinusitis occurs when the sinuses swell and is most often caused by infection or allergy. Most sinusitis is easily cleared up within 2 weeks, and so it is only ratable if it is Chronic. Sinusitis can occur in each of the different sinuses or in all at the same time (“pansinusitis”). Treatments range from medication to surgery.
If the sinusitis is constant or near-constant with headaches, tenderness to the touch, and the discharge of puss or crusting after repeated surgeries, or if a Radical Surgery was performed and there is ongoing infection in the facial bones (osteomyelitis), it is rated 50%.
If there are 3 or more Incapacitating Episodes each year that requires 4 to 6 weeks of antibiotic treatment, or if there are more than 6 episodes (not incapacitating) each year of headaches, tenderness and the discharge of puss or crusting, it is rated 30%.
If there are 1 or 2 incapacitating episodes each year that requires 4 to 6 weeks of antibiotic treatment, or if there are 3 to 6 episodes each year of headaches, tenderness, and the discharge of puss or crusting, it is rated 10%.
Anything less is rated 0%.
· Code 6510: Pansinusitis
· Code 6511: Ethmoid sinusitis
· Code 6512: Frontal sinusitis
· Code 6513: Maxillary sinusitis
· Code 6514: Sphenoid sinusitis
-Proposed- Rhinosinusitis Rating System
Rhinosinusitis occurs when the sinuses and nasal cavity swell, making it difficult to breathe through the nose.
Most cases of rhinosinusitis are easily cleared up in less than 12 weeks. These cases are not ratable.
Only cases of rhinosinusitis that have symptoms lasting 12 weeks or more during the past year—Rhinosinusitis (CRS) and Recurrent Acute Rhinosinusitis (RARS)—can be rated.
Symptoms of rhinosinusitis include inflammation proven by radiographic imaging or by visual confirmation of purulent mucus or polyps and at least two of the following:
· Mucus drainage
· Congestion
· Facial pressure/pain/fullness
· Decreased sense of smell
A 50% rating is given if the condition requires antibiotic treatment 12 weeks or more during the past year and is unresponsive to surgical treatments.
A 30% rating is given if the condition requires antibiotic treatment 12 weeks or more during the past year.
A 10% rating is given if the condition requires antibiotic treatment for 4-12 weeks during the past year.
A 0% rating is given if the condition requires antibiotic treatment less than 4 weeks during the past year.
Rhinosinusitis codes:
Code 6222: Pansinusitis
Code 6223: Ethmoid rhinosinusitis
Code 6224: Frontal rhinosinusitis
Code 6225: Maxillary rhinosinusitis
Code 6226: Sphenoid rhinosinusitis
-NEW CODE- Code 6233: Allergic or vasomotor rhinosinusitis
The VA is proposing multiple changes to the sinusitis ratings, including updating the terminology to current standards and clearly clarifying what kinds of rhinosinusitis can qualify for ratings. They are also getting rid of the vague “incapacitating episodes” requirements and basing the ratings on measurable periods of time where antibiotics were required to treat the condition.
The VA is also proposing adding a new rhinosinusitis condition to ensure accurate ratings.
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The following codes will be changing numbers, but their ratings will not change:
Code 6515 for tuberculous laryngitis will become code 6227.
Code 6516 for chronic laryngitis will become code 6228.
Code 6518 for a total laryngectomy will become code 6229.
Code 6519 for complete aphonia will become code 6230.
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-Current- Code 6520: Stenosis of the larynx is when the larynx narrows and the opening to the trachea becomes unusually small, causing difficulty speaking and breathing. If the larynx was injured, then any leftover symptoms from the injury can also be rated under this code. These conditions are either rated on the following system, or as the inability to speak, code 6519, whichever is most appropriate for the condition and provides the higher rating.
If the FEV-1 is less than 40% and the Flow-Volume Loop shows an upper airway obstruction, or if there is a Permanent Tracheostomy, then it is rated 100%. If the FEV-1 is 40-55% and the Flow-Volume Loop shows an upper airway obstruction, it is rated 60%. If the FEV-1 is 56-70% and the Flow-Volume Loop shows an upper airway obstruction, it is rated 30%. If the FEV-1 is 71-80% and the Flow-Volume Loop shows an upper airway obstruction, it is rated 10%.
-Proposed- Code 6231: Stenosis of the larynx is when the larynx narrows and the opening to the trachea becomes unusually small, causing difficulty speaking and breathing. If the larynx was injured, then any leftover symptoms from the injury can also be rated under this code.
These conditions are either rated on the following system, or as the inability to speak, code 6230, whichever is most appropriate for the condition and provides the higher rating.
A 100% rating is given if the larynx is completely blocked and requires a permanent tracheostomy to breathe.
A 70% rating is given if 50% or more of the larynx is blocked.
A 50% rating is given if 25-49% of the larynx is blocked.
A 30% rating is given if less than 25% of the larynx is blocked.
Currently, larynx stenosis is rated on the results of breathing tests, but the VA is proposing to rate it solely on the amount the larynx has narrowed. They argue that other conditions can result in similar test results, so the disability resulting from only the stenosis can better be determined simply by measuring the blockage.
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Code 6521 for injuries of the pharynx will become code 6232. The ratings will not change.
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-Current- Code 6522: Allergic or vasomotor rhinitis is the swelling of the tissues lining the nasal passage because of allergies or other inhaled triggers like smoke, fumes, etc. This causes the nose to become stuffy and runny. If the rhinitis is fairly constant and there are growths forming in the tissues, it is rated 30%. If there are no growths in the tissues, but 50% of the nasal passages on both sides or 100% on one side is blocked, it is rated 10%.
-Proposed- Code 6240: Allergic or vasomotor rhinitis is the swelling of the tissues lining the nasal passage because of allergies or other inhaled triggers like smoke, fumes, etc. This causes the nose to become stuffy and runny.
A 30% rating is given if there are growths (“polyps”) forming in the tissues.
A 10% rating is given if it requires continuous medication, like corticosteroids and antihistamines.
If the condition results in chronic or recurrent rhinosinusitis, it is rated under code 6233.
The VA is only proposing to change the 10% rating to be based solely on whether or not continuous medication is needed for the condition.
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-Current- Code 6523: Bacterial rhinitis is the swelling of the tissues lining the nasal passage because of a bacterial infection, causing congestion and a runny nose. If the condition causes rhinoscleroma, it is rated 50%. If there is rhinitis and the Nasal Concha grows abnormally into the nasal passages and causes 50% of both or 100% of one to be blocked, it is rated 10%.
- Proposed- Code 6234: Rhinosinusitis caused by infection is the swelling of the tissues lining the nasal passage because of a bacterial or fungal infection. It is rated under the Rhinosinusitis Rating System.
The VA is proposing to change the name of this condition so it is clear that it includes both bacterial and fungal infections. It will then be rated on the new Rhinosinusitis Rating System.
-Current- Code 6524: Granulomatous rhinitis is the swelling of the tissues lining the nasal passage with abnormal cell growths that are not caused by bacteria. If the condition is lethal midline Wegener’s granulomatosis, it is rated 100%. This condition causes the blood vessels in the nose to swell and lumps to form that often cause deformities to form and the airways to become blocked. The condition is not curable, but it is treatable and not always lethal. Any other type of rhinitis that causes lumps to form in the nose is rated 20%.
-Proposed- Code 6235: Rhinosinusitis (granulomatous, autoimmune, or other) is the swelling of the tissues lining the nasal passage with abnormal cell growths caused by fungal infections, autoimmune disorders, etc. The rhinosinusitis rated under this code is very severe and can be life-threatening.
A 100% rating is given while the condition is being treated with systemic immunosuppressive medications. The 100% rating continues for 6 months following the last treatment. It is then rated under the Rhinosinusitis Rating System.
All other cases are rated under the Rhinosinusitis Rating System.
Lethal midline granuloma and all other cancerous conditions are rated under code 6238.
The modern medical understandings and treatments of these conditions have changed significantly, so the VA is proposing to adjust the ratings and conditions rated under this code in order to more correctly and accurately rate these conditions.
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-NEW Proposed Code- Code 6236: Vocal cord paralysis occurs when nerves that control the vocal cords are damaged. It is rated either under code 6228, laryngitis, or code 6230, aphonia, whichever best describes the resulting disability.
The VA is proposing to add a new code for vocal cord paralysis in order to ensure correct and consistent ratings for veterans with this condition.
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-NEW Proposed Code- Code 6237: Benign tumors affecting the nose, throat, and/or sinuses are rated on how they affect the functioning of the affected part. It is rated under the code that most closely describes the resulting symptoms.
-NEW Proposed Code- Code 6238: Malignant tumors affecting the nose, throat, and/or sinuses are rated 100% while they are active. The 100% rating continues for 6 months following the final treatment of the condition. It is the re-evaluated and rated under the code that most closely describes the remaining symptoms.
The VA is proposing to add new codes specifically for tumors of the nose, throat, and sinuses in order to better track these conditions in the veteran population. No changes are being made to the ratings for these conditions.
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-NEW Proposed Code- Code 6239: Salivary gland conditions affect the production of the saliva and often result in dry mouth and other symptoms.
A 20% rating is given if there is dry mouth, altered sense of taste, and difficulty chewing and swallowing food, leading to either weight loss or tooth decay.
A 10% rating is given if there is dry mouth, altered sense of taste, and difficulty chewing and swallowing food, but no weight loss or tooth decay. A 10% is also given if the salivary gland always swells and hurts when eating or if there are blocks or strictures in the salivary gland.
A 0% rating is given if there is dry mouth, but no pain or difficulty eating.
Facial nerve damage, code 8207, and disfigurement, code 7800, can be rated separately.
The VA is proposing to add a new code for conditions of the salivary gland, which currently doesn’t have a satisfactory rating option.