Proposed Changes to the Respiratory System
Proposed Changes to the Respiratory System
On February 15th, 2022, the VA published proposed changes to the ratings of the Respiratory System.
These were published along with changes to the Ears, Nose, and Throat which we discuss here.
The current VA Schedule Of Ratings (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 move the Nose and Throat conditions out of the Respiratory System and combine them with the Ears since they are associated together in modern medicine.
The following are the VA’s new proposed changes to the ratings for the Respiratory System. 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.
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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.
You can find all the proposed changes to the Nose and Throat conditions in our post discussing the Ear, Nose, and Throat section.
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Respiratory Rating System
The Respiratory Rating System is fairly extensive, so we aren’t going to reproduce the entire thing here. You can find the current system on our site via the link above.
-Proposed- Respiratory Rating System
The Respiratory Rating System is used to rate all respiratory conditions unless otherwise noted.
Only a single respiratory condition can be rated. If multiple conditions are present, the one that causes the main disability is rated. If, however, the overall respiratory picture is more severe than is covered by this rating, the rating can be increased to the next highest rating.
The only condition that can be rated in addition to other respiratory conditions is Sleep Apnea.
Ratings for respiratory conditions are based on how well the lungs take in air, absorb oxygen into the blood, and then exhale the left-over gases. Pulmonary function tests (PFTs) are performed to record the proper functioning of the lungs and their effects on the entire body.
Every PFT is not required when the VO2 Max has been tested and is 20 ml/kg/min or less, there has been one or more episodes of respiratory failure, or when regular oxygen therapy is needed outside of a medical facility.
When deciding which test result to use to rate the condition, the one that the examining physician feels most closely reflects the nature of the condition must be used. If they all accurately reflect the condition, then the one that gives the highest rating can be used. If any of the test results are not consistent with the other tests or overall condition, then the examining physician must explain why that test result should not be used to rate the condition.
If there is a heart condition in addition to the respiratory condition, only one can be rated using METs. The other condition must be rated on other rating criteria.
The ratings:
The VA is proposing significant changes to the Respiratory Rating System in order to update the tests, ratings, and practices to modern medical understandings.
The ratings themselves will not change very much, but the VA is removing the heart condition ratings, so those can be rated separately, and the rating for oxygen use since this no longer accurately reflects the level of disability. They are also adding rating options for additional PFTs, as well as METs, which are already used to rate heart conditions related to respiratory conditions. This will align the respiratory and heart ratings to create more consistency.
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Code 6660, chronic bronchitis, continues to be rated on the Respiratory Rating System.
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-Current- Code 6601: Bronchiectasis is a condition where part of the bronchial tree becomes enlarged and causes obstruction of the airflow. This is a permanent condition that cannot be reversed.
It is either rated on the Respiratory Rating System or on incapacitating episodes below, whichever provides the highest rating. The definition of an “incapacitating episode” for rating this condition is a period where there is an active infection in the lungs, and it requires bed rest and treatment by a physician.
If there are a total of at least 6 weeks of incapacitating episodes each year, it is rated 100%.
If there are a total of 4 to 6 weeks of incapacitating episodes each year, or if there is constant coughing of mucous mixed with puss or blood that requires near-constant antibiotic treatment with anorexia and weight loss, it is rated 60%.
If there are a total of 2 to 4 weeks of incapacitating episodes each year, or if there is daily coughing occasionally of muscous mixed with puss or blood that requires between 4 to 6 weeks of antibiotic treatment 3 or more times a year, it is rated 30%.
If there is occasional coughing with infections requiring antibiotics 2 or more times a year, it is rated 10%.
-Proposed- Code 6601: Bronchiectasis is a condition where part of the bronchial tree becomes enlarged and causes obstruction of the airflow. This is a permanent condition that cannot be reversed. It is rated on the Respiratory Rating System.
The VA proposes to remove rating requirements based on vague incapacitating episodes and simply rate this condition on the new Respiratory Rating System.
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Codes 6603, pulmonary emphysema, and 6604, chronic obstructive pulmonary disease, continue to be rated on the Respiratory Rating System.
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The VA is proposing very few changes for code 6602, asthma, so we won’t reproduce the entire thing here. The only significant change is to update the FEV-1 requirements for the 100% rating to less than 45% and the 60% rating to 45-55%. Everything less remains the same.
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Code 6730 for active pulmonary tuberculosis remains the same.
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-Current- Code 6731: Inactive pulmonary tuberculosis is rated on the lasting symptoms or complications. If it causes restrictive heart disease or interstitial lung disease, then it will be rated on those conditions. Obstructive lung disease is rated as chronic bronchitis under code 6600, and a Thoracoplasty is rated under code 5297.
-Proposed- Code 6731: Inactive pulmonary tuberculosis is rated on the Respiratory Rating System. If a thoracoplasty was performed, it is rated under code 5297.
The VA proposes to rate inactive tuberculosis on the new Respiratory Rating System as they feel this system accurately covers the residuals of pulmonary tuberculosis.
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Code 6732 for tuberculous pleurisy remains the same.
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-Current- Code 6817: All pulmonary vascular diseases are rated under this code. These conditions affect the blood vessels leading to and from the lungs.
If the condition causes Pulmonary hypertension, Chronic Pulmonary Thrombo-embolism with pulmonary hypertension, Right Ventricular Hypertrophy, right heart failure, or pulmonary hypertension with right heart failure or right ventricular hypertrophy caused by the blockage of arteries or veins in the lungs, it is rated 100%.
If the condition causes pulmonary thrombo-embolism that requires anticoagulant therapy, it is rated 60%. A 60% rating is also given if surgery has been done on the Inferior Vena Cava and there is no evidence of pulmonary hypertension or any other problems with the right ventricle.
If there has been a pulmonary embolism and it has been treated and cleared, but the conditions still causes symptoms, it is either rated 30% under this code or it can be rated under the code of the symptom (like 6600 for bronchitis or 6844 for pleural effusion or fibrosis), whichever provides the highest rating. Only one code can be used, however, even if there are multiple symptoms. If there are no symptoms, it is rated 0%.
-Proposed- Code 6817: Pulmonary thromboembolic disease occurs when blood clots travel to the blood vessels leading to and from the lungs.
A 100% rating is given if the arteries or veins are consistently blocked and there is either pulmonary hypertension or right ventricular hypertrophy.
A 60% rating is given if the condition requires anticoagulant therapy or if surgery has been done on the Inferior Vena Cava and there is no evidence of pulmonary hypertension or any other problems with the right ventricle.
A 30% rating is given if the clot has been cleared, but the condition still causes symptoms. If it provides a higher rating, the condition can instead be rated under the code of the main symptom (like 6600 for bronchitis or 6844 for pleural effusion or fibrosis). Only one code can be used, however, even if there are multiple symptoms.
A 0% rating is given if the clot has been cleared and there are no symptoms.
This condition cannot be rated in addition to a heart condition, so when both are present, a single rating is given for the main disability. The only respiratory condition that can be rated in addition to this code is sleep apnea.
The VA proposes to change the name of this condition to “pulmonary thromboembolic disease” stating that this is the more commonly used name in modern medicine. The ratings are not significantly changing, but the 100% rating for primary pulmonary hypertension is being removed as this condition will now be rated under its own code (see below), and the overall criteria simplified to focus on the main disabilities caused by this condition.
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-Proposed NEW Code- Code 6849: Chronic pulmonary hypertension is high blood pressure between the lungs and the heart. The condition can cause the right ventricle of the heart to swell, resulting in poor lung and heart function.
It is rated on the size of the right ventricle and pulmonary/cardiovascular test results: VO2 Max, METs, and BNPs. VO2 Max and METs are discussed in the Respiratory Rating System. Brain natriuretic peptides (BNP) are a type of protein made by the heart when it is failing. The higher the number, the worse the heart failure.
A 100% rating is given if the right ventricle is more than 4 cm and either the VO2 Max is less than 15 or there are 3 METs or less.
A 60% rating is given if the right ventricle is more than 4 cm and either the VO2 Max is 15-20, there are 3.1-5.0 METs, or the BNP is greater than 500.
A 30% rating is given if the right ventricle is 3-4 cm and either there are 5.1-7.0 METs or the BNP is 100-500.
A 0% rating is given if either the VO2 Max is greater than 20 or the BNP is less than 100.
This condition cannot be rated in addition to a heart condition, so when both are present, a single rating is given for the main disability. The only respiratory condition that can be rated in addition to this code is sleep apnea.
The VA proposes to add a new code for pulmonary hypertension as it is currently rated analogously, but none of the current codes fully cover the unique symptoms it can cause. The new rating system considers how the condition affects both the lungs and the heart.
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-Current- Code 6819: Any malignant cancer of the respiratory system (not including skin growths) is rated 100% while it is active. This 100% rating continues for 6 months following the last treatment. The condition is then re-evaluated and any left-over symptoms or complications are rated separately.
-Current- Code 6820: Any tumor of the respiratory system is rated on any systems or functions that it affects. For example, if the tumor pushes on the Larynx and makes it hard to speak, then it would be rated as aphonia, code 6519.
-Proposed- Code 6819: Any malignant cancer of the respiratory system (not including skin growths) is rated 100% while it is active. This 100% rating continues for 6 months following the last treatment. The condition is then re-evaluated and rated on the Respiratory Rating System.
-Proposed- Code 6820: Any tumor of the respiratory system is rated on the Respiratory Rating System.
The only proposed change to these codes is for any residuals to be rated on the Respiratory Rating System.
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For all Interstitial Lung Diseases, the VA proposes removing the current rating system, and instead rating all of these conditions (codes 6825-6833 and 6846) on the Respiratory Rating System. The current system is already similar, but with fewer rating options, so this will broaden the rating requirements.
The proposed ratings also add an additional 10% to any rating for these conditions if they are being treated either with more than 20mg of oral prednisone daily or with daily non-steroidal immunosuppressive medications.
Non-steroidal immunosuppressives include, but are not limited to, azathioprine, cyclophosphamide, colchicine, penicillamine, and etanercept.
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Codes 6834-6839 for Mycotic Lung Diseases remain the same.
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For all Restrictive Lung Diseases, the VA proposes removing the current rating system, and instead rating all of these conditions (codes 6840-6845) on the Respiratory Rating System. The current system is already similar, but with fewer rating options, so this will broaden the rating requirements.
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-Current- Code 6847: Any sleep apnea syndrome is rated under this code. Sleep apnea is a disorder that occurs while asleep. There is either a pause when breathing that can last up to a few minutes or there is very shallow, low breathing. Central sleep apnea is caused by a decrease in the “action” of breathing—the body doesn’t try as hard to breathe properly. Obstructive sleep apnea is caused by a block in the airways, like a narrowing of the airway passages or an excess of mucus. This causes severe snoring. Mixed sleep apnea is a combination of both central and obstructive.
Sleep apnea can cause a significant impairment of the heart and respiratory system by limiting the amount of air that is taken in during the hours of sleep.
If the condition continues over a long period of time and causes respiratory failure with right heart ventricle failure or with too much carbon dioxide in the blood stream, or if it requires a Tracheotomy, it is rated 100%.
If it requires the use of breathing machines like a continuous positive airway pressure (CPAP) machine during sleep, it is rated 50%.
If it causes serious sleepiness during the daytime or not feeling rested after sleeping, it is rated 30%.
If it is diagnosed by a sleep test, but it doesn’t cause any significant symptoms, it is rated 0%.
-Proposed- Code 6847: Any sleep apnea syndrome is rated under this code. Sleep apnea is a disorder that occurs while asleep. There is either a pause when breathing that can last up to a few minutes or there is very shallow, low breathing.
Central sleep apnea is caused by a decrease in the “action” of breathing—the body doesn’t try as hard to breathe properly. Obstructive sleep apnea is caused by a block in the airways, like a narrowing of the airway passages or an excess of mucus. This causes severe snoring. Mixed sleep apnea is a combination of both central and obstructive.
Sleep apnea can cause a significant impairment of the heart and respiratory system by limiting the amount of air that is taken in during the hours of sleep.
A 100% rating is given if there is end-organ damage (damage of the heart, kidneys, brain, or eyes) and the condition does not respond to treatment or cannot be treated.
A 50% rating is given if the condition does not respond to treatment or cannot be treated.
A 10% rating is given if the symptoms are only partially resolved with treatment.
A 0% rating is given if the symptoms are fully resolved with or without treatment.
The VA is proposing huge changes for sleep apnea. Currently, it is rated on the treatments required for management. However, the purpose of the ratings is to compensate veterans for loss of earning capacity. The VA therefore proposes instead to rate sleep apnea on any symptoms that remain after treatment. This does put these ratings more in line with the ratings for other conditions, but will make it harder to receive a higher rating under this code.
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-Proposed NEW Code- Code 6848: Lung transplants are rated under this code. The condition is rated 100% for 1 year following discharge from the hospital after the surgery. It is then rated on the Respiratory Rating System based on any remaining symptoms with a minimum 30% rating.
The VA proposes adding a code for lung transplants in order to ensure consistent and correct ratings.