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Rating % For Spinal Fusion?

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blackbird

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Does anyone know if there is a set % rating for a spinal fusion Code #5241, or is the % for a fusion still tied to range of motion? I've found the code but haven't found a rating for it. I realize that sometimes several codes are combined for a total rating as long as it isn't pyramiding.

Also, I thought I read somewhere that veterans are reimbursed for copays for doctors, medicine, hospitals etc that where incurred after a claim was declared service connected. If this is true, is there a total percentage that you have to be disabled to get reimbursed?

Thanks in advance for you response,

Blackbird

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I might not be reading this right, but per 38 CFR 4.71(a), which is posted below, your code is 5241. They are supposed to treat these based on ROM, incapaciting episodes, abnormal gait, or abnormal contour. The percentage would be based on this criteria. Note 5 also may apply if the ankylosis/fusion is severe enough to incapicitate the entire section. I'm still learning myself, but just trying to help.

Are you meaning to say that you paid out of pocket for copays, doctors, etc... and then got SC granted and want to know if you could get reimbursed for it back to your EED?

Regarding reimbursement, this is what I was able to find, but doesn't really go into details in my previous sentence.

http://www.hadit.com/forums/index.php?show...st&p=168319

The Spine

Rating General Rating Formula for Diseases and Injuries of the Spine

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating

Intervertebral Disc Syndrome Based on Incapacitating Episodes):

With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease

Unfavorable ankylosis of the entire spine 100

Unfavorable ankylosis of the entire thoracolumbar spine 50

Unfavorable ankylosis of the entire cervical spine; or, forward flexion

of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of

the entire thoracolumbar spine 40

Forward flexion of the cervical spine 15 degrees or less; or, favorable

ankylosis of the entire cervical spine 30

Forward flexion of the thoracolumbar spine greater than 30 degrees but not

greater than 60 degrees; or, forward flexion of the cervical spine greater

than 15 degrees but not greater than 30 degrees; or, the combined range of

motion of the thoracolumbar spine not greater than 120 degrees; or, the

combined range of motion of the cervical spine not greater than 170 degrees;

or, muscle spasm or guarding severe enough to result in an abnormal gait

or abnormal spinal contour such as scoliosis, reversed lordosis, or

abnormal kyphosis 20

Forward flexion of the thoracolumbar spine greater than 60 degrees but not

greater than 85 degrees; or, forward flexion of the cervical spine greater than

30 degrees but not greater than 40 degrees; or, combined range of motion of

the thoracolumbar spine greater than 120 degrees but not greater than 235

degrees; or, combined range of motion of the cervical spine greater than

170 degrees but not greater than 335 degrees; or, muscle spasm, guarding,

or localized tenderness not resulting in abnormal gait or abnormal spinal

contour; or, vertebral body fracture with loss of 50 percent or more of the

height 10

Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.

Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.

Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted.

Note (4): Round each range of motion measurement to the nearest five degrees.

Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

5235 Vertebral fracture or dislocation

5236 Sacroiliac injury and weakness

5237 Lumbosacral or cervical strain

5238 Spinal stenosis

5239 Spondylolisthesis or segmental instability

5240 Ankylosing spondylitis

5241 Spinal fusion

5242 Degenerative arthritis of the spine (see also diagnostic code 5003)

5243 Intervertebral disc syndrome

Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25.

Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes

With incapacitating episodes having a total duration of at least 6 weeks during the

past 12 months 60

With incapacitating episodes having a total duration of at least 4 weeks but less than

6 weeks during the past 12 months 40

With incapacitating episodes having a total duration of at least 2 weeks but less than

4 weeks during the past 12 months 20

With incapacitating episodes having a total duration of at least one week but less than

2 weeks during the past 12 months 10

Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment.

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  • HadIt.com Elder
Does anyone know if there is a set % rating for a spinal fusion Code #5241, or is the % for a fusion still tied to range of motion? I've found the code but haven't found a rating for it. I realize that sometimes several codes are combined for a total rating as long as it isn't pyramiding.

Also, I thought I read somewhere that veterans are reimbursed for copays for doctors, medicine, hospitals etc that where incurred after a claim was declared service connected. If this is true, is there a total percentage that you have to be disabled to get reimbursed?

Thanks in advance for you response,

Blackbird

5241 is the DC for fusion. Rate according to range of motion.

As long as the conditionis service connected you can ask for a Review of your prescription co pays and ask for the money you paid for that condition back to the effective date of the award.

If the award is 50 percent or more, you can ask for all co payments to be reimbursed to the effective date of 50 percent.

J

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  • HadIt.com Elder

If you have constant pain you should probably claim chronic paid disorder to get a few percentage points added on to your rating. I have back pain and it makes me depressed.

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5241 is the DC for fusion. Rate according to range of motion.

As long as the conditionis service connected you can ask for a Review of your prescription co pays and ask for the money you paid for that condition back to the effective date of the award.

If the award is 50 percent or more, you can ask for all co payments to be reimbursed to the effective date of 50 percent.

J

Thanks jbasser for the response to my questions. If I understand correctly I would have to file a new claim if SC for the medicine copays, right?

Blackbird

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If you have constant pain you should probably claim chronic paid disorder to get a few percentage points added on to your rating. I have back pain and it makes me depressed.

Thanks John999,

I'm not familiar with "Chronic Pain Disorder", is there a code number seperate for this?

Blackbird

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I might not be reading this right, but per 38 CFR 4.71(a), which is posted below, your code is 5241. They are supposed to treat these based on ROM, incapaciting episodes, abnormal gait, or abnormal contour. The percentage would be based on this criteria. Note 5 also may apply if the ankylosis/fusion is severe enough to incapicitate the entire section. I'm still learning myself, but just trying to help.

Are you meaning to say that you paid out of pocket for copays, doctors, etc... and then got SC granted and want to know if you could get reimbursed for it back to your EED?

Regarding reimbursement, this is what I was able to find, but doesn't really go into details in my previous sentence.

http://www.hadit.com/forums/index.php?show...st&p=168319

Thanks Vync, Very interesting.

Blackbird

The Spine

Rating General Rating Formula for Diseases and Injuries of the Spine

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating

Intervertebral Disc Syndrome Based on Incapacitating Episodes):

With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease

Unfavorable ankylosis of the entire spine 100

Unfavorable ankylosis of the entire thoracolumbar spine 50

Unfavorable ankylosis of the entire cervical spine; or, forward flexion

of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of

the entire thoracolumbar spine 40

Forward flexion of the cervical spine 15 degrees or less; or, favorable

ankylosis of the entire cervical spine 30

Forward flexion of the thoracolumbar spine greater than 30 degrees but not

greater than 60 degrees; or, forward flexion of the cervical spine greater

than 15 degrees but not greater than 30 degrees; or, the combined range of

motion of the thoracolumbar spine not greater than 120 degrees; or, the

combined range of motion of the cervical spine not greater than 170 degrees;

or, muscle spasm or guarding severe enough to result in an abnormal gait

or abnormal spinal contour such as scoliosis, reversed lordosis, or

abnormal kyphosis 20

Forward flexion of the thoracolumbar spine greater than 60 degrees but not

greater than 85 degrees; or, forward flexion of the cervical spine greater than

30 degrees but not greater than 40 degrees; or, combined range of motion of

the thoracolumbar spine greater than 120 degrees but not greater than 235

degrees; or, combined range of motion of the cervical spine greater than

170 degrees but not greater than 335 degrees; or, muscle spasm, guarding,

or localized tenderness not resulting in abnormal gait or abnormal spinal

contour; or, vertebral body fracture with loss of 50 percent or more of the

height 10

Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.

Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.

Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted.

Note (4): Round each range of motion measurement to the nearest five degrees.

Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

5235 Vertebral fracture or dislocation

5236 Sacroiliac injury and weakness

5237 Lumbosacral or cervical strain

5238 Spinal stenosis

5239 Spondylolisthesis or segmental instability

5240 Ankylosing spondylitis

5241 Spinal fusion

5242 Degenerative arthritis of the spine (see also diagnostic code 5003)

5243 Intervertebral disc syndrome

Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25.

Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes

With incapacitating episodes having a total duration of at least 6 weeks during the

past 12 months 60

With incapacitating episodes having a total duration of at least 4 weeks but less than

6 weeks during the past 12 months 40

With incapacitating episodes having a total duration of at least 2 weeks but less than

4 weeks during the past 12 months 20

With incapacitating episodes having a total duration of at least one week but less than

2 weeks during the past 12 months 10

Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment.

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