IBS
Irritable bowel syndrome — diagnostic code 7319
10%, 20%, 30%. Thirty percent is the top of this code.
- 10% — Abdominal pain related to defecation at least one day during the previous three
months; and two or more of the six symptoms listed below.
- 20% — Abdominal pain related to defecation for at least three days per month during
the previous three months; and two or more of the six symptoms below.
- 30% — Abdominal pain related to defecation at least one day per week during the
previous three months; and two or more of the six symptoms below.
The only thing that changes between 10, 20 and 30 is how often the pain comes. The symptom
requirement is the same two-of-six at every level. There is no "significant functional impairment"
test and no "most severe" test in this code. If a chart told you that, it was adding a bar the
regulation does not set.
The six symptoms are a closed list. Two or more of: (1) change in stool frequency,
(2) change in stool form, (3) altered stool passage — straining and/or urgency, (4) mucorrhea —
mucus in the stool, (5) abdominal bloating, (6) subjective distension — feeling swollen or
distended. That is the whole list. "Diarrhea" and "constipation" are not items on it — they count
only as a change in stool frequency or a change in stool form. An exam that documents symptoms
outside these six does not satisfy the criterion, so make sure your provider's words land inside it.
★ Frequency of pain, plus two of six.
GERD
GERD and esophageal stricture — diagnostic code 7206
0%, 10%, 30%, 50%, 80%.
Know this before you read the levels. Under DC 7206 as rewritten May 19, 2024, every level
is built around a documented esophageal stricture — a narrowing of the food pipe. With no
documented stricture, the evaluation is 0% no matter how bad the reflux is. Daily
heartburn medication by itself does not earn 10% under this code.
- 0% — Documented history of esophageal stricture(s) without daily symptoms or
requirement for daily medications.
- 10% — Documented history of esophageal stricture(s) that requires daily medications to
control dysphagia (trouble swallowing), otherwise asymptomatic.
- 30% — Recurrent esophageal stricture(s) causing dysphagia which requires dilatation up
to two times per year.
- 50% — Documented history of recurrent or refractory esophageal stricture(s) causing
dysphagia which requires at least one of: (1) dilatation 3 or more times per year, (2) dilatation
using steroids at least one time per year, or (3) esophageal stent placement.
- 80% — Documented history of recurrent or refractory esophageal stricture(s) causing
dysphagia with at least one of: (1) aspiration, (2) undernutrition, and/or (3) substantial
weight loss as defined by 38 CFR 4.112(a); and treatment with either surgical correction of the
stricture(s) or a percutaneous esophago-gastrointestinal tube (PEG tube — a feeding tube placed
through the belly wall).
Two places a narrow reading costs money. At 50%, the standard is not "frequent" dilatation —
three dilatations in a year, or one steroid dilatation in a year, is enough. At 80%, you do
not need aspiration and undernutrition and weight loss. You need one of
those three, plus the surgery or the PEG tube. A veteran with aspiration and a PEG tube meets 80%.
And "substantial weight loss" is a defined term under 38 CFR 4.112(a) — it is not the rater's
opinion, so have your provider measure it against that definition.
★ No stricture in the file, no rating.
GERD — the fine print
The notes under 7206 decide the claim
These are part of the code. Raters apply them. Most charts leave them off.
- Note (1) — the evidence. Findings must be documented by barium swallow, computerized
tomography (CT), or esophagogastroduodenoscopy (EGD — a scope passed down the throat). This whole
code now turns on a documented stricture, so get that report into your file before you file.
- Note (2). Non-gastrointestinal complications of procedures are rated under the
appropriate body system.
- Note (4) — what "recurrent" means. Recurrent esophageal stricture is defined as the
inability to maintain target esophageal diameter beyond 4 weeks after the target diameter has
been achieved.
- Note (5) — what "refractory" means. Refractory esophageal stricture is defined as the
inability to achieve target esophageal diameter despite receiving no fewer than 5 dilatation
sessions performed at 2-week intervals.
Note (3) — this code is bigger than GERD. In VA's own words, DC 7206 "applies, but is not
limited to, esophagitis, mechanical or chemical; Mallory Weiss syndrome (bleeding at junction of
esophagus and stomach due to tears) due to caustic ingestion of alkali or acid; drug-induced or
infectious esophagitis due to Candida, virus, or other organism; idiopathic eosinophilic, or
lymphocytic esophagitis; esophagitis due to radiation therapy; esophagitis due to peptic
stricture; and any esophageal condition that requires treatment with sclerotherapy." If one of
those is your diagnosis, this is still your code. Do not walk away because the chart said "GERD."
★ "Recurrent" and "refractory" are defined, not judgment calls.
Hemorrhoids
Hemorrhoids — diagnostic code 7336
The current criteria. The old "mild or moderate" and "large or thrombotic" wording
is gone from this code.
- 0% — Assigned under 38 CFR 4.31 when the 10% criteria are not met.
- 10% — Prolapsed internal hemorrhoids (pushed outside the body) with two or less
episodes per year of thrombosis (a clot forming in the hemorrhoid); or external hemorrhoids with
three or more episodes per year of thrombosis.
- 20% — Internal or external hemorrhoids with persistent bleeding and anemia (low red
blood cell count); or continuously prolapsed internal hemorrhoids with three or more episodes per
year of thrombosis.
20% is the maximum schedular rating for hemorrhoids. That has not changed.
What did change: the old route to 20% through fissures was deleted from this code on
May 19, 2024, and so was the old "mild or moderate" 0% level. Counting thrombosis episodes per
year is now the test at both 10% and 20%, so the episode count needs to be in your medical record.
★ Count the episodes. Get them documented.
Before May 19, 2024
If your claim or appeal reaches back before that date
The old hemorrhoid criteria still matter for periods before the rewrite, and for many
of those periods they are the better path.
The old DC 7336 text, which applies only to periods before May 19, 2024:
0% — Mild or moderate hemorrhoids.
10% — Large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue and frequent
recurrences.
20% — Persistent bleeding with secondary anemia, or hemorrhoids with fissures.
That old "or with fissures" route to 20% still applies to any appeal period before May 19, 2024,
and it is usually the better path for those periods. If your claim or appeal covers time before
that date, say so in writing and ask that the pre-May-19-2024 criteria be considered for that
earlier period. Do not let anyone apply only the new wording to old time.
★ Old time, old rules. Raise it yourself.
Two rules that decide money
Zero percent, double-counting, and fissures
- A code with no 0% line still gives a 0%. DC 7319 prints no 0% level. Under 38 CFR 4.31,
"in every instance where the schedule does not provide a zero percent evaluation for a diagnostic
code, a zero percent evaluation shall be assigned when the requirements for a compensable
evaluation are not met." A 0% is not a denial. It is service connection on the books, and it is
what you build an increase on later.
- You cannot be paid twice for the same symptom. 38 CFR 4.114 does not bar combining
DC 7336 with codes outside its list, but 38 CFR 4.14 still forbids evaluating the same
manifestation twice. Because the DC 7336 20% criterion already includes anemia, a separate
anemia evaluation for that same anemia is pyramiding and will be denied. A separate evaluation is
available only for a genuinely distinct disability with distinct manifestations — so if you are
going after a second evaluation, build it on a different disability, not on the same bleeding.
- Anal fissure has no code of its own. Current 38 CFR 4.114 contains no diagnostic code
for anal fissure — the word "fissure" does not appear in the section at all. That door is closed,
and here is the next one: on or after May 19, 2024 a service-connected anal fissure is rated by
analogy under 38 CFR 4.20 to the closest analogous code, such as DC 7332 (impairment of sphincter
control), DC 7333 (stricture of rectum and anus), or DC 7335 (ano, fistula in). Which one fits
depends on your facts. For any period before May 19, 2024, the old DC 7336 fissure route above is
still there.
★ A closed door is not the end of the road.
If you hold an older rating
DC 7346 is not an escape hatch anymore
Hiatal hernia, diagnostic code 7346.
DC 7346 still exists and is now titled "Hiatal hernia and paraesophageal hernia," but its entire
criteria now read: "Rate as esophagus, stricture of (DC 7203)." On or after May 19, 2024
that code routes to the same stricture-based scale as DC 7203 and DC 7206. The old symptom-based
wording people remember under 7346 — heartburn, regurgitation, arm or shoulder pain — is not
available going forward. If somebody tells you to file under 7346 to get around the stricture
requirement, that advice is out of date.
★ Same scale, different door.