In order to ensure that you’re getting the most out of your disability claim, it is important to understand how your condition is rated. Errors are frequently made when rating conditions. The VA not only makes mistakes in evaluation the severity of a condition, but sometimes they evaluate a condition according to the completely wrong rating criteria. Today’s blog post will cover spinal conditions that are not rated under the general rating formula. Specifically, this blog post will cover ratings for degenerative arthritis, traumatic arthritis, and rheumatoid arthritis. The rating systems used for arthritis of the spine is the second most common rating system for spine conditions. There are two types of arthritis that are rated under the same rating system; degenerative arthritis, and traumatic arthritis. The third type of arthritis being discussed today, rheumatoid arthritis, is rated under its own rating system.
Degenerative Arthritis & Traumatic Arthritis
Degenerative arthritis is the chronic breakdown of the cartilage surrounding the joints. Degenerative arthritis of the spine, sometimes referred to as facet joint osteoarthritis, causes a breakdown of the cartilage between the facet joints in the back of the spine. Lack of cartilage causes pain and limitation of motion. Traumatic arthritis occurs after an injury, excessive movement, or other physical trauma. Traumatic arthritis causes symptoms similar to other types of arthritis such as pain, inflammation, and build-up of fluid around the affected joint.
All conditions involving arthritis (both degenerative arthritis and traumatic arthritis), regardless of the joint affected are rated under diagnostic code 5003. Depending on what joint is affected, there will be an identifying diagnostic code assigned to the condition. For example, the specific code for degenerative arthritis of the spine is 5242. However, degenerative arthritis of the spine will be rated under the criteria listed for diagnostic code 5003. Because there are technically two diagnostic codes associated with one condition, you would see the condition listed on rating decisions as 5242-5003. The diagnostic code for traumatic arthritis is 5010. So if a veteran has traumatic arthritis in his spine, the final diagnostic code would appear as 5010-5003. Think of the first number as an identifying diagnostic code that tells you what joint is affected, while the second diagnostic code tells you the rating system the condition is being rated under.
Arthritis will only be rated under diagnostic code 5003, when the condition does not result in severe enough limitation of motion to be rated under the general rating formula for the spine (this rating formula was discussed in part 1 of the spine claims blogs). If there is decreased range of motion of the cervical or thoracolumbar spine, the condition would be rated according to the general rating formula for the spine that is based off of range of motion measurements. Another requirement for a spine condition to be rated under the code for degenerative arthritis is that there must be x-ray evidence of arthritis in the cervical or thoracolumbar joints.
As mentioned above, many different joints are rated under the rating criteria for degenerative arthritis. This includes the shoulder, wrist, elbow, hip, knee ankle, fingers, toes, spine, and the sacroiliac joint. Some joints are referred to as major joints, while others are referred to as minor joints. The spine is considered as a minor joint. The rating assigned under the rating criteria for degenerative arthritis depends on how many joint groups are affected and whether there is painful motion. If two or more major OR minor groups are affected a 20% rating will be assigned if the arthritis is occasionally incapacitating. If the arthritis does not cause any episodes of incapacitation, but 2 or more joint groups are involved, then a 10% rating will be assigned. If a veteran only has one joint group affected by arthritis then there must also be painful motion present in order for a rating higher than 0% to be assigned. If there is painful motion, a 10% rating will be assigned. For example, if a veteran has degenerative arthritis of the spine with no other joints affected, and he experiences pain when bending over he will receive a 10% rating.
Rheumatoid arthritis is a disease that causes destruction of the joints in the body. Although this type of arthritis is most common in the small joints of the hands and feet, it can occur in any joint of the body. When rheumatoid arthritis affects the spine, it typically affects the cervical spine (the neck) rather than the thoracolumbar spine (the low back). Rheumatoid arthritis of the spine leads to neck pain, back pain, and sometimes causes pain to radiate into the arms and legs. Symptoms involved are similar to the symptoms involved with degenerative arthritis and include pain and swelling of the joints.
The diagnostic code for rheumatoid arthritis is 5002. Rating percentages are assigned based on the frequency of incapacitating episodes. The following percentages are available under the rating criteria for rheumatoid arthritis:
- 100% if you are completely incapacitated and are confined to staying in bed
- 60% if there are severe incapacitating episodes that occur 4 or more times per year
- 40% if there are incapacitating episodes that occur 3 or more times per year if there is a definite (but not necessarily significant) decrease in health
- 20% if there are less than 3 incapacitating episodes per year
It is possible for rheumatoid arthritis to be rated under diagnostic code 5003 like degenerative and traumatic arthritis. If the condition is not severe enough to meet the above criteria, then the rating will be based on specific symptoms. For example, if rheumatoid arthritis of the spine results in pain with motion, the condition will be rated according to the criteria set forth in 5003 as described above.