8498 Federal Register / Vol. 87, No. 31 / Tuesday, February 15, 2022 / Proposed Rules 

APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES—Continued 

Diagnostic 

code No. 

*******

Septum, nasal, deviation of ..................................................................................................................................................................... 6220 

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Sleep apnea syndromes .......................................................................................................................................................................... 6847 

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Vocal cord paralysis ................................................................................................................................................................................ 6236 

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[FR Doc. 2022–02049 Filed 2–14–22; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 4 

RIN 2900–AQ82 

Schedule for Rating Disabilities: 

Mental Disorders 

AGENCY: Department of Veterans Affairs. 

ACTION: Proposed rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) proposes to amend the 

portion of the rating schedule dealing 

with mental disorders, including 

revising the General Rating Formula for 

Mental Disorders and combining 

currently separate General Rating 

Formula for Mental Disorders with the 

General Rating Formula for Eating 

Disorders in the VA Schedule for Rating 

Disabilities (VASRD or rating schedule). 

The proposed rule reflects changes 

made by the American Psychiatric 

Association’s Diagnostic and Statistical 

Manual of Mental Disorders 5 (DSM–5), 

advances in medical knowledge, and 

recommendations from VA’s Mental 

Disorders Work Group. 

DATES: VA must receive comments on or 

before April 18, 2022. 

ADDRESSES: Comments may be 

submitted through 

www.Regulations.gov. Comments 

received will be available at 

www.Regulations.gov for public 

viewing, inspection or copies. 

FOR FURTHER INFORMATION CONTACT: 

Ioulia Vvedenskaya, M.D., M.B.A., 

Medical Officer, Regulations Staff, 

(210A), Compensation Service, Veterans 

Benefits Administration, Department of 

Veterans Affairs, 810 Vermont Avenue 

NW, Washington, DC 20420, 

211PolicyStaff.Vbavaco@va.gov, (202) 

461–9700. (This is not a toll-free 

telephone number.) 

SUPPLEMENTARY INFORMATION: 

I. The Need for Updated Rating Criteria 

As part of its ongoing revision of the 

VASRD, VA proposes changes to the 

rating schedule for mental disorders, 

including the General Rating Formula 

for Mental Disorders codified at 38 CFR 

4.130. The proposed changes would 

update evaluation criteria based on the 

DSM–5, medical advances since the last 

substantive revision of the rating 

schedule for mental disorders in 1996, 

and current understanding of functional 

impairment associated with, or resulting 

from, mental disorders. These changes 

also reflect comments received from 

subject matter experts in the Veterans 

Benefits Administration (VBA), 

Veterans Health Administration (VHA), 

Board of Veterans’ Appeals (BVA), 

Department of Defense (DoD), and 

Veterans Service Organizations (VSOs). 

Overall, VA did not rely on one 

particular input for these proposed 

changes, but the multitude of published, 

publicly available, and peer-reviewed, 

scientific and medical sources cited 

below. 

In 2006, the Veterans’ Disability 

Benefits Commission (VDBC) asked the 

Institute of Medicine (IOM) (now named 

the National Academy of Medicine) to 

study and recommend improvements 

for the VASRD. The IOM recommended 

updating the medical content of the 

rating schedule, by placing greater 

emphasis on a disabled veteran’s ability 

to function in the work setting, rather 

than focusing on symptoms alone. 

Institute of Medicine, ‘‘A 21st Century 

System for Evaluating Veterans for 

Disability Benefits’’ 113–14 (Michael 

McGeary et al. eds., 2007). 

In March 2015, VA published a final 

rule (RIN 2900–AO96) that updated the 

nomenclature for mental disorders and 

removed outdated references to the 

fourth editions of DSM (DSM–IV and 

DSM–IV–TR), replacing them with 

references to the latest fifth edition 

(DSM–5). While this rule updated the 

nomenclature to conform to the DSM– 

5, VA did not update the rating criteria 

used to evaluate mental disorders. 

VA now proposes, however, to update 

the rating criteria for mental disorders 

in accord with IOM’s recommendation 

and the latest medical science. VA’s 

updates are based on the framework 

associated with the International 

Classification of Functioning, Disability, 

and Health (ICF) and its companion 

assessment instrument, the World 

Health Organization (WHO) Disability 

Assessment Schedule 2.0 (WHODAS 

2.0), as well as the International 

Classification of Diseases (ICD), and 

concepts and methodology from the 

DSM–5. 

The WHODAS 2.0 is a validated 

instrument that assesses health and 

disability across all diseases, including 

mental, neurological, and addictive 

disorders. O. Garin et al., ‘‘Validation of 

the ‘World Health Organization 

Disability Assessment Schedule, 

WHODAS–2’ in patients with chronic 

diseases,’’ 8 Health and Quality of Life 

Outcomes 51 (2010). It assesses the 

ability to perform tasks in six functional 

domains by measuring the impact of a 

disability across various life functions 

and assigning a score for each domain. 

‘‘WHO Disability Assessment Schedule 

2.0 (WHODAS 2.0),’’ World Health 

Organization, https://www.who.int/ 

classifications/icf/whodasii/en/ (last 

visited Nov. 19, 2019) (hereinafter 

‘‘WHODAS 2.0’’). 

The ICD is a standard tool for the 

diagnosis of disabilities for the purposes 

of epidemiology, health management, 

and clinical practice. By employing a 

standardized numerical labeling system, 

the ICD allows disease to be classified, 

monitored, and analyzed for statistical 

purposes. ‘‘Classifications,’’ World 

Health Organization, https://

www.who.int/classifications/en/ (last 

visited Nov. 19, 2019). 

Finally, the DSM–5 is a standardized 

classification of mental disorders for 

mental health professionals in the 


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United States. The DSM–5 contains 

every mental health disorder recognized 

by the American Psychiatric Association 

and provides detailed diagnostic 

criteria. As a standard for mental health, 

the DSM–5 is also used to collect data 

regarding public health matters 

involving psychiatric disorders. See 

generally American Psychiatric 

Association (APA), ‘‘Diagnostic and 

Statistical Manual of Mental Disorders’’ 

(American Psychiatric Publishing, 5th 

ed. 2013) (hereinafter ‘‘DSM–5’’). 

Previous versions of the DSM relied 

upon a categorical diagnostic 

classification scheme requiring a 

clinician to determine whether a 

disorder was absent or present with a 

multiaxial system, each axis of which 

gave a different type of information 

about the diagnosis. Axis V, in 

particular, was comprised of the Global 

Assessment of Functioning (GAF) scale, 

which was used by clinicians to assess 

an individual’s overall level of 

functioning on a hypothetical 

continuum of mental health illness. 

The DSM–5 eliminates the multiaxial 

approach and instead provides for a 

‘‘dimensional approach, which allows a 

clinician more latitude to assess the 

severity of a condition.’’ APA, ‘‘DSM– 

5’s Integrated Approach to Diagnosis 

and Classifications,’’ https://

www.psychiatry.org/File%20Library/ 

Psychiatrists/Practice/DSM/APA_DSM5-Integrated-Approach.pdf. According 

to the APA, a growing body of scientific 

evidence supports multi-faceted or 

multi-dimensional concepts in assessing 

functional impairment due to mental 

disorders. DSM–5 at 733–737. 

Clinicians who assess the consequences 

of mental disorders should consider a 

combination of all domains of 

functioning, and a comprehensive 

approach incorporates variations of 

features within the individual, rather 

than relying on a simple combination of 

presented symptoms. Id. 

This dimensional approach 

incorporates differential severity of 

individual symptoms both within and 

outside of a disorder’s diagnostic 

criteria as measured by intensity, 

duration, or number of symptoms, along 

with other features such as type and 

severity of disabilities. DSM–5 at 733. In 

sum, the dimensional approach is 

consistent with current diagnostic 

practice and comprehensively examines 

the functional consequences of a mental 

disability. Id.; see Lonnie R. Bristow, 

Preface to ‘‘A 21st Century System for 

Evaluating Veterans for Disability 

Benefits’’ xii (some of the signature 

injuries incurred in Operations 

Enduring Freedom/Iraqi Freedom, such 

as posttraumatic stress disorder (PTSD), 

must be evaluated in terms of their 

functional consequences). Accordingly, 

the DSM–5 now advocates for 

assessments like the WHODAS 2.0, 

which ‘‘has proven useful as a 

standardized measure of disability for 

mental disorders.’’ DSM–5 at 21. The 

WHODAS 2.0 corresponds to concepts 

contained in the WHO’s ICF. T. 

Bedirhan U ̈ stu ̈n et al., ‘‘Developing the 

World Health Organization Disability 

Assessment Schedule 2.0,’’ Bull. World 

Health Organ. 815 (2010) (hereinafter 

‘‘Developing WHODAS 2.0’’). The 

WHODAS 2.0 does not depend on 

symptom levels. Rather, the WHODAS 

2.0 is a 36-item or 12-item measure that 

assesses an individual’s performance 

over the past 30 days in activities in the 

following six domains (areas of 

functioning): (1) Understanding and 

communication; (2) getting around; (3) 

self-care; (4) getting along with people; 

(5) life activities; and (6) participation in 

society. World Health Organization, 

‘‘Measuring Health and Disability 

Manual for WHO Disability Assessment 

Schedule WHODAS 2.0’’ 4–5 (T.B. 

U ̈ stu ̈n et al. eds., 2010) (hereinafter 

‘‘Manual’’). The WHODAS 2.0 asks how 

much difficulty the individual has had 

performing certain activities within 

each domain using the following scale: 

No difficulty (1), mild difficulty (2), 

moderate difficulty (3), severe difficulty 

(4), and extreme difficulty or cannot do 

(5). Id. at 38, 41. 

The WHODAS 2.0 is similar to the 

Clinician-Administered PTSD Scale for 

DSM–5 (CAPS–5), which is the ‘‘gold 

standard in PTSD assessment.’’ See 

Frank W. Weathers et al., ‘‘The 

Clinician-Administered PTSD Scale for 

DSM–5 (CAPS–5)’’ (2013), cited at 

https://www.ptsd.va.gov/professional/ 

assessment/adult-int/caps.asp (last 

visited Nov. 19, 2019) (hereinafter 

‘‘Weathers 2013’’); Frank W. Weathers et 

al., ‘‘The Clinician-Administered PTSD 

Scale for DSM–5 (CAPS–5): 

Development and Initial Psychometric 

Evaluation in Military Veterans,’’ 

Psychol. Assess. 30(3) (2018), available 

at https://www.ncbi.nlm.nih.gov/pmc/ 

articles/PMC5805662/ (last visited Nov. 

19, 2019). The CAPS–5 is a 30-item 

structured interview administered by 

clinicians and clinical researchers that 

is used to render a diagnosis of PTSD 

and assess the severity of the 20 PTSD 

symptoms in the DSM–5 based on 

symptom frequency and intensity using 

a scale similar to the WHODAS 2.0, i.e., 

absent (0), mild (1), moderate (2), severe 

(3), and extreme (4). See Weathers 2013, 

supra. The scores for frequency and 

intensity are combined to form a single 

severity score for each symptom, and a 

total severity score is calculated by 

combining all the individual severity 

scores for the 20 PTSD symptoms. Id. 

There is evidence that a standardized 

assessment for disability related to 

mental disorders, such as the WHODAS 

2.0 and CAPS–5, leads to a more reliable 

and valid disability examination 

process. IOM, ‘‘Psychological Testing in 

the Service of Disability Determination’’ 

66 (2015), https://www.nap.edu/read/ 

21704. The WHODAS 2.0 ‘‘has good 

psychometric qualities, including good 

reliability and item-response 

characteristics’’ and shows concurrent 

validity when compared with other 

measures of disability or health status or 

with clinician ratings. Developing 

WHODAS 2.0, supra. A VA study 

compared clinical interviews with 

standardized assessments that 

incorporated the CAPS–5 for PTSD 

diagnosis and the WHODAS 2.0 for 

functional impairment and found that 

administering a standardized disability 

assessment resulted in more complete 

assessment of functional impairment 

and diagnostic coverage of PTSD. Ted 

Speroff et al., ‘‘Compensation and 

Pension Examination for PTSD,’’ VA 

Office of Health Services Research & 

Development Service Forum 7 (May 

2012). VA therefore proposes a General 

Rating Formula for Mental Disorders, h 

is explained below, that would provide 

a standardized assessment of disability 

similar to the WHODAS 2.0 and CAPS– 

5. It would also create a common 

language between clinicians and 

adjudicators, which VA believes will 

lead to more efficient and accurate 

adjudication of claims for mental 

disorders. 

Another important purpose for 

updated rating criteria is the fact that, 

since September 11, 2001, the United 

States has deployed more than 2.5 

million American service members to 

Iraq, Afghanistan, and other dangerous 

regions around the world. These 

deployments have exposed service 

members to a variety of stressors, 

including sustained risk of, and 

exposure to, injury and death, as well as 

an array of family pressures. U.S. 

Department of Defense, ‘‘DoD, VA, 

Other Agencies Team to Study PTSD, 

TBI,’’ American Forces Press Service 

(Aug. 14, 2013) https://

archive.defense.gov/News/NewsArticle.

aspx?ID=120620 (last visited Nov. 19, 

2019). Multiple deployments involve 

prolonged exposure to combat-related 

stressors. The psychological toll of these 

deployments must be taken seriously. 

RAND Corporation, Preface to ‘‘Invisible 

Wounds of War: Psychological and 

Cognitive Injuries, Their Consequences, 

and Services to Assist Recovery’’ iii (T. 


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Tanielian & L.H. Jaycox eds., 2008). 

Recent reports have referred to PTSD 

and traumatic brain injury (TBI) as the 

signature wounds of the conflicts in 

Afghanistan and Iraq. Id. With 

increasing incidence of suicide and 

suicide attempts among returning 

veterans, concern about depression and 

other mental health disorders is also on 

the rise. 

Indeed, individuals with mental 

disorders such as depression, anxiety 

and adjustment disorders frequently 

experience recurrent absences from 

work. I. Arends et al., ‘‘Prevention of 

Recurrent Sickness Absence in Workers 

with Common Mental Disorders: Results 

of a Cluster-Randomized Controlled 

Trial,’’ 71 Occupational Envtl Med. 21 

(2014). As compared to physical 

disorders, mental disorders cause less 

engagement in life activities, including 

work. M.A. Buist-Bouwman et al., 

‘‘Comparing Functioning Associated 

with Mental and Physical disorders,’’ 

113 Acta Psychiatr. Scand. 499 (2006). 

One comprehensive study based on a 

WHO questionnaire estimated that 

employees with bipolar disorder lost the 

equivalent of about 28 work days 

annually from sick time and other 

absences. ‘‘Mental health problems in 

the workplace,’’ Harvard Mental Health 

Letter (Feb. 2010), https://www.health.

harvard.edu/newsletter_article/mentalhealth-problems-in-the-workplace; see 

also N.L. Kleinman et al., ‘‘Lost Time, 

Absence Costs, and Reduced 

Productivity Output for Employees With 

Bipolar Disorder,’’ 47 J. Occupational & 

Envtl. Med. 1117, 1121 (Nov. 2005). 

Moreover, compared to the general 

population, the risk of recurrent 

sickness absence is higher for 

employees with mental disorders, and 

such recurrent absences are often more 

serious and long-lasting. See 71 

Occupational Envtl Med. at 21. 

As the understanding of mental 

disorders has advanced, so has the 

ability to recognize and quantify the 

components that form both the 

diagnosis as well as its attendant 

disability. Therefore, VA proposes to 

update the section of the rating schedule 

that addresses mental disorders to 

provide clear, consistent, and accurate 

evaluation criteria. Updating the 

General Rating Formula for Mental 

Disorders will also improve the 

timeliness and accuracy of 

adjudications by providing uniform 

objective criteria based on modern 

medical science. 

Finally, the proposed changes are 

necessary to address potential 

inadequacies in the current mental 

health criteria of the VASRD. In August 

2007, the Center for Naval Analyses 

(CNA) prepared an earnings loss study 

in response to a request from the VDBC 

to assess compensation levels under the 

VASRD. Eric Christensen et al., ‘‘Final 

Report for the Veterans’ Disability 

Benefits Commission: Compensation, 

Survey Results, and Selected Topics’’ 

(CNA 2007). The study found that those 

veterans with primary mental 

disabilities do not receive adequate 

compensation to offset any earnings 

losses. Id. at 193. On the basis of its 

findings, CNA recommended that VA 

review and adjust evaluations for 

mental disorders to provide adequate 

compensation for earnings losses. Id. 

Another study, completed by 

Economic Systems, Inc. (EconSys), in 

September 2008, focused on the 

adequacy of VA benefits to compensate 

for loss of earnings and functional 

impairment. EconSys, ‘‘A Study of 

Compensation Payments for ServiceConnected Disabilities’’ (2008). Like 

CNA, EconSys found that veterans with 

mental disorders generally were 

undercompensated by the VASRD. Id. at 

33. EconSys also recommended a reevaluation of the criteria for mental 

disorders, noting that VA should update 

the VASRD to reflect modern medical 

science. Id at 35. 

Given the foregoing, VA proposes to 

adopt new evaluation criteria that more 

accurately capture the occupational 

impairment caused by mental 

disabilities and provide more adequate 

compensation for the earnings losses 

experienced by veterans with serviceconnected mental disorders. A more 

detailed discussion of the specific 

evaluation criteria VA proposes and 

how VA will apply it follows. 

II. The Current Rating Schedule and a 

New Framework for Evaluation 

The current rating schedule for 

mental disorders provides two separate 

rating formulas, the General Rating 

Formula for Mental Disorders and the 

Rating Formula for Eating Disorders. 

The General Rating Formula for Mental 

Disorders bases evaluations on a list of 

signs and symptoms that 

characteristically produce a particular 

level of disability. 61 FR 52695, 52700 

(Oct. 8, 1996). VA believes that an 

updated formula considering the 

severity, frequency and duration of 

symptoms would provide the most 

accurate and consistent method for 

evaluating functional impairment. 

The current Rating Formula for Eating 

Disorders bases evaluations on the 

extent of weight loss, incapacitating 

episodes, and required periods of 

hospitalization, in accordance with the 

now-outdated DSM–IV. 60 FR 54825, 

54829 (Oct. 26, 1995). VA believes that 

an updated formula can better evaluate 

how symptoms or episodes attributable 

to eating disorders actually translate 

into functional and occupational 

impairment. 

As noted above, the understanding of 

disability resulting from mental 

disorders has evolved with the science. 

The IOM report recognized that some of 

the signature injuries (e.g., PTSD) 

incurred in Operations Enduring 

Freedom/Iraqi Freedom are not visible 

or subject to a laboratory test. See also 

Bristow, supra. Instead, they must be 

evaluated in terms of their functional 

consequences. Id. In that regard, 

properly evaluating mental disability 

requires the ability to recognize and 

quantify the components that form the 

diagnosis as well as resulting 

impairment. While symptoms determine 

the diagnosis, they do not necessarily 

translate directly to functional 

impairment. Thus, we believe that, in 

order to accurately measure functional 

impairment, VA must consider the 

frequency and severity of the symptoms 

and how they impact functioning and 

performance across a variety of 

domains: That, is aspects of human 

behavior and functioning. 

To ensure evaluations are accurate 

and consistent with modern medicine, 

VA is proposing a new, comprehensive 

general rating formula for all mental 

disorders, to include eating disorders. 

The proposed evaluation criteria will 

measure a veteran’s essential ability to 

participate in the work environment and 

the impact of the mental disorder on 

earning capacity via a comprehensive 

assessment of occupational and social 

functioning. Diagnoses must still be 

established according to the DSM–5. 38 

CFR 4.125(a). However, once an 

examiner has diagnosed a specific 

mental disorder, the proposed rating 

criteria will enable VA to assign an 

evaluation by analyzing the frequency, 

intensity, and overall severity of 

occupational and social impairment due 

to the diagnosed mental disorder and in 

accordance with the updated clinical 

standards of the DSM–5. 

The proposed evaluation criteria, as 

further discussed below, encapsulate 

the dimensional approach of the 

WHODAS 2.0, ICD, DSM–5, and CAPS– 

5. 

III. The Proposed General Rating 

Formula for Mental Disorders 

A. Domains of Functional Impairment 

Congress requires VA to base its rating 

schedule, ‘‘as far as practicable, upon 

the average impairments of earning 

capacity’’ in ‘‘civil occupations’’ that a 

veteran will experience due to the 


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disability in question. 38 U.S.C. 1155. 

VA recognizes that a veteran’s earning 

capacity after disability is highly 

dependent upon both occupational and 

social functioning. Studies have shown 

that the objective evaluation of 

functional performance, rather than 

subjective criteria, is a strong predictor 

of impairment in earning capacity in 

individuals with a diagnosed mental 

disorder. A. Galvao et al., ‘‘Predicting 

Improvement in Work Status of Patients 

With Chronic Mental Illness After 

Vocational and Integrative 

Rehabilitation Measurements,’’ 44 

Rehabilitation 208, 208–14 (2005). VA 

has therefore determined that a 

multidimensional approach to 

evaluating mental disorders will 

provide the most efficient and 

satisfactory method for measuring the 

impact of mental health disabilities on 

a veteran’s earning capacity. 

VA would continue to require that a 

diagnosis of a mental disorder be 

established in accordance with the 

DSM–5 as required by 38 CFR 4.125(a). 

However, for purposes of rating the 

extent of disability attributable to a 

mental disorder, VA proposes a rating 

formula using five domains of 

functioning to evaluate the extent of 

disability, similar to the approach of the 

WHODAS 2.0. 

As explained above, the WHODAS 2.0 

assesses an individual’s ability to 

perform life activities based upon six 

domains (areas of functioning): (1) 

Understanding and communicating, (2) 

ability to move and get around, (3) 

caring for oneself, (4) getting along with 

people, (5) carrying out life activities, 

and (6) participating in society. 

However, ‘‘getting along with people’’ 

and ‘‘participation in society’’ can 

essentially be categorized as one domain 

of ‘‘interpersonal interactions and 

relationships’’ for VA’s purpose of 

evaluating a veteran’s earning capacity. 

38 U.S.C. 1155. Therefore, the proposed 

General Rating Formula for Mental 

Disorders would evaluate the extent of 

a veteran’s disability based upon all 

evidence of record relevant to the 

following five domains: (1) Cognition 

(i.e., understanding and 

communicating), (2) interpersonal 

interactions and relationships (i.e., 

interacting with people and 

participating in society), (3) task 

completion and life activities, (4) 

navigating environments (i.e., getting 

around), and (5) self-care. 

The domain of ‘‘Cognition’’ would 

assess a veteran’s mental processing 

involved in gaining knowledge and 

comprehension. These processes 

include, but are not limited to, memory, 

concentration, attention, goal setting, 

speed of processing information, 

planning, organizing, prioritizing, 

problem solving, judgment, decision 

making, or flexibility in adapting when 

appropriate. 

The domain of ‘‘Interpersonal 

Interactions and Relationships’’ would 

assess a veteran’s ability to effectively 

interact with other people in both social 

and occupational settings and 

participate in society. This domain 

includes both informal (social, 

associational, etc.) and formal 

(coworkers, supervisors, etc.) 

relationships. 

The domain of ‘‘Task Completion and 

Life Activities’’ would assess a veteran’s 

ability to manage task-related demands. 

This domain includes, but is not limited 

to, the following types of activities: 

Vocational, educational, domestic 

chores, social, or caregiving. 

The domain of ‘‘Navigating 

Environments’’ would assess a veteran’s 

physical and mental ability to go from 

place to place. This domain includes, 

but is not limited to, the following: 

leaving the home, being in confined or 

crowded spaces, independently moving 

in surroundings, navigating new 

environments, driving, or using public 

transportation. 

The domain of ‘‘Self-Care’’ would 

assess a veteran’s ability to take care of 

himself or herself. This domain would 

include, but would not be limited to, the 

following types of activities: Hygiene, 

dressing appropriately, or nourishment. 

B. Assessing the Level of Functioning 

In order to accurately measure 

occupational and social impairment due 

to a mental disorder, VA proposes to 

measure a veteran’s functioning within 

each of the five domains discussed 

above based upon the level of difficulty 

the veteran experiences in performing 

tasks associated with the domain 

(intensity) and the percentage of time 

that these difficulties occur (frequency). 

See Jon D. Elhai et al., ‘‘Posttraumatic 

Stress Disorder’s Frequency and 

Intensity Ratings Are Associated With 

Factor Structure Differences in Military 

Veterans,’’ 22 Psychol. Assess. 723 

(2010); A.J. Rush, Jr., et al., ‘‘Handbook 

of Psychiatric Measures’’ 103–05 

(American Psychiatric Publishing, 2d 

ed. 2008). This approach would be 

outlined in 38 CFR 4.126(a), which will 

state that, when evaluating a mental 

disorder, an adjudicator must consider 

the intensity and frequency of 

psychiatric symptoms that bear on the 

five domains discussed above. Section 

4.126(a) would also state that VA will 

assess the intensity and frequency of 

symptoms in each domain and will 

assign an evaluation based on the 

combined levels of functioning in these 

domains as explained in the General 

Rating Formula For Mental Disorders. 

VA would delete paragraph (b) of 

current section 4.126, which provides 

that VA will consider social impairment 

but will not assign an evaluation ‘‘solely 

on the basis of social impairment,’’ as 

obsolete, because that principle would 

be more clearly addressed in one of the 

domains for assessment, providing for 

consideration of ‘‘interpersonal 

interactions and relationships.’’ 

Paragraphs (c) and (d) would be 

redesignated as paragraphs (b) and (c), 

respectively. 

As to the proposed General Rating 

Formula, there will be 100, 70, 50, 30, 

and 10 percent evaluations based on the 

severity of impairment in all five 

domains. To measure the severity in an 

individual domain, VA will first 

evaluate the intensity of impairment in 

that domain. Intensity refers to the 

difficulties in functioning, i.e., 

interference with completing tasks. The 

levels of intensity for each domain will 

be none, mild, moderate, severe, or 

total, generally defined as follows: 

‘‘None’’—‘‘No difficulties’’ associated with 

the domain; 

‘‘Mild’’—‘‘Slight difficulties in one or more 

aspects’’ of the domain that ‘‘do not interfere 

with tasks, activities, or relationships;’’ 

‘‘Moderate’’—‘‘Clinically significant 

difficulties in one or more aspects’’ of the 

domain ‘‘that interfere with tasks, activities, 

or relationships;’’ 

‘‘Severe’’—‘‘Serious difficulties in one or 

more aspects’’ of the domain ‘‘that interfere 

with tasks, activities, or relationships;’’ 

‘‘Total’’—‘‘Profound difficulties in one or 

more aspects’’ of the domain ‘‘that cannot be 

managed or remediated; incapable of even 

the most basic tasks within one or more 

aspects’’ of the domain; ‘‘difficulties that 

completely interfere with tasks, activities, or 

relationships.’’ 

As a technical note, the ‘‘task 

completion and life activities’’ domain 

uses slightly different criteria to define 

these levels, and several of the domains 

consider the effect of accommodations 

or assistance in their assessment. 

When evaluating intensity under the 

proposed criteria, examiners and VA 

adjudicators should be cognizant of the 

fact that some symptoms may overlap 

between domains. VA will provide 

training or additional guidance to help 

avoid the artificial inflation of the 

severity of a condition through the 

double-counting of symptoms. Cf. 38 

CFR 4.14. Moreover, consistent with 38 

U.S.C. 1155 (VASRD shall compensate 

for impairments in earning capacity), 

examiners and VA adjudicators 

generally should assess impairments 

with a view toward their effect on 

earning capacity. Finally, examiners and 


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VA adjudicators generally should assess 

impairments due to the serviceconnected disability, not other causes. 

See ICF Checklist (Version 2.1a, 

Clinician Form) (‘‘The level of capacity 

should be judged relative to that 

normally expected of the person, or the 

person’s capacity before they acquired 

their health condition.’’), https://

www.who.int/classifications/icf/ 

icfchecklist.pdf?ua=1; see also Manual 

at 39 (WHODAS 2.0 responses should 

address difficulties with activities due 

to health conditions, rather than to other 

causes). Again, training and additional 

guidance will be provided to VA 

personnel for further edification on 

appropriately applying the revised 

general rating formula. 

After determining the intensity for 

each domain, VA would address 

frequency. Frequency refers to the 

percentage of time, in the past month, 

that impairment occurs. Consistent with 

the WHO’s ICF Checklist rates and the 

CAPS–5, VA proposes to differentiate 

between impairment occurring less than 

25 percent of the time over the past 

month, and 25 percent of the time or 

more over the past month. The CAPS– 

5 distinguishes in its ratings between a 

frequency of ‘‘some of the time’’ (20 to 

30 percent) and more frequent 

occurrences. Weathers 2013, supra. The 

WHO’s ICF checklist, upon which the 

WHODAS 2.0 is based, similarly 

distinguishes between impairments that 

are present less than 25 percent of the 

time and those occurring more than 25 

percent of the time in the past month. 

See ICF Checklist, pt. 2; see also Manual 

at 39 (‘‘Recall abilities are most accurate 

for the period of one month.’’). Like 

other validated measures, VA recognizes 

that impairments that occur 25 percent 

or more of the time present a greater 

impact on social and occupational 

functioning than those that occur less 

frequently. 

Consideration of both the intensity 

and frequency would yield the level of 

impairment of functioning in each 

domain, and each level would correlate 

to a numerical value, ranging from 0 to 

4, which would be defined as follows: 

‘‘0 = None’’—‘‘No difficulties;’’ 

‘‘1 = Mild impairment at any frequency; or 

moderate impairment that occurs less than 

25% of the time;’’ 

‘‘2 = Moderate impairment that occurs 25% 

or more of the time; or severe impairment 

that occurs less than 25% of the time;’’ 

‘‘3 = Severe impairment that occurs 25% 

or more of the time; or total impairment that 

occurs less than 25% of the time;’’ and 

‘‘4 = Total impairment that occurs 25% or 

more of the time.’’ 

C. Assigning a Disability Rating 

Once an adjudicator determines the 

level of impairment of functioning for 

each domain caused by a mental 

disorder, VA would assign an 

evaluation of 10, 30, 50, 70, or 100 

percent for the disorder based upon the 

numerical value for each domain and 

the number of domains affected. VA 

would assign the following ratings 

based upon the following criteria: 

Disability rating 

Score 

Level of impairment 

(0–4) 

Number of affected 

domains 

100 .......................................................................................................................................... 4 in 1 or more domains. 

3 in 2 or more domains. 

70 ............................................................................................................................................ 3 in 1 domain. 

2 in 2 or more domains. 

50 ............................................................................................................................................ 2 in 1 domain. 

30 ............................................................................................................................................ 1 in 2 or more domains. 

10 ............................................................................................................................................ Minimum rating. 

As reflected in this formula, veterans 

who have more severe impairment in 

more domains will receive higher 

ratings. Veterans with less severe 

impairment in less domains will receive 

lower ratings. But, notably, a numerical 

value of 4 in just one domain will 

warrant a 100 percent rating; and a 

numerical value of 3 in just one domain 

will warrant a 70 percent rating. This 

criterion should generally lead to more 

generous compensation for veterans 

than the current rating formula, which 

requires ‘‘total occupational and social 

impairment’’ for a 100 percent rating 

and ‘‘deficiencies in most areas’’ for a 70 

percent rating. Moreover, VA proposes 

to eliminate the current rating formula’s 

provision for a noncompensable rating, 

and to provide a minimum rating of 10 

percent for all mental disorders. This is 

because a disorder that meets the DSM– 

5 requirements for being a mental 

disorder must include elements 

indicative of both harm and 

dysfunction. Michael B. First et al., 

‘‘Diagnostic Criteria as Dysfunction 

Indicators: Bridging the Chasm Between 

the Definition of Mental Disorder and 

Diagnostic Criteria for Specific 

Disorders,’’ 58 Canadian J. of Psychiatry 

663, 665 (Dec. 2013). Thus, a DSM–5 

disorder will rarely produce zero 

dysfunction. Id. Because the DSM–5 

requirements represent thresholds of 

minimal clinical confidence that a 

dysfunction is present, VA will assign at 

least a 10 percent rating for such 

disorders. Id. at 668. 

IV. Elimination of Rating Formula for 

Eating Disorders 

As previously noted, current § 4.130 

includes two separate rating formulae 

for mental disorders—the General 

Rating Formula for Mental Disorders 

and the Rating Formula For Eating 

Disorders. VA created a separate 

Formula for Eating Disorders ‘‘because 

their more disabling aspects are 

manifested primarily by physical 

findings rather than by psychological 

symptoms.’’ 60 FR at 54829. The current 

Rating Formula for Eating Disorders 

bases evaluations on the extent of 

weight loss, incapacitating episodes, 

and required periods of hospitalization. 

Id. However, in the DSM–5 at 339, the 

only eating disorder for which weight is 

a diagnostic criterion is anorexia 

nervosa, and body mass index (BMI) 

(weight in kilograms divided by height 

in meters squared (kg/m2)) is used to 

specify the current severity of the 

disorder. Weight and BMI are not 

diagnostic criteria in the DSM–5 for 

other eating disorders, such as bulimia 

nervosa and binge-eating disorder, nor 

are they specifiers for the severity of 

other eating disorders. DSM–5 at 329– 

54. 

As explained above, assessments like 

the WHODAS 2.0 can be used to assess 

an individual’s ability to perform life 

activities based upon six areas of 

functioning as a result of any disorder, 

including eating disorders. Liza H. Gold, 

‘‘DSM–5 and the Assessment of 

Functioning: The World Health 

Organization Disability Assessment 

Schedule 2.0 (WHODAS 2.0),’’ 42 J. Am 


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Acad. Psychiatry L. 173, 174–75 (2014). 

The test-retest reliability, internal 

consistency, and concurrent validity of 

the WHODAS 2.0 in comparison to 

other instruments for measuring 

disability has been established in 

various patient populations and in 

general population samples. Manual at 

19–25. Based upon the diagnostic 

criteria and severity specifiers for most 

eating disorders in the DSM–5 and the 

universal applicability of the WHODAS 

2.0, VA no longer sees a need for a 

separate rating formula for eating 

disorders, and VA proposes to instead 

evaluate the extent of disability caused 

by eating disorders based upon the 

effect of an individual’s disorder on the 

five domains of functioning under the 

General Rating Formula for Mental 

Disorders discussed above. VA seeks 

comment on this approach. 

V. Proof-of-Concept Study 

To derive the appropriate level to 

assign to each domain (e.g., 0 through 

4), VA conducted a proof-of-concept 

study with 100 veterans with serviceconnected mental disorders. Commonly 

known as feasibility studies, proof-ofconcept studies are designed to examine 

new methods or treatments. The results 

of such studies improve the program or 

evaluation procedure before using it on 

a larger scale. L. Thabane et al., ‘‘A 

tutorial on pilot studies: the what, why, 

and how,’’ BMC Medical Research 

Methodology 10:1, https://

www.biomedcentral.com/content/pdf/ 

1471-2288-10-1.pdf (last visited Nov. 19, 

2019). 

VA identified four specific aims of the 

proof-of-concept study to examine the 

feasibility of the proposed rating criteria 

for mental disorders. The first objective 

was to examine the distribution of 

evaluations under the current and 

proposed rating criteria for mental 

disorders. The second objective was to 

examine the extent to which the revised 

Mental Disorders Disability Benefits 

Questionnaire (DBQ) would adequately 

collect information needed to rate 

disabilities based upon the proposed 

rating criteria. The third objective was 

to examine the extent to which 

adjudicators were easily able to extract 

rating data from the revised DBQ and 

apply the new evaluation criteria. The 

fourth objective was to examine the 

extent to which Compensation and 

Pension (C&P) examiners found the 

revised DBQ adequate and easy to use. 

Regarding the first objective, the 

proof-of-concept study found that the 

proposed General Rating Formula for 

Mental Disorders would increase the 

average disability evaluation. Compared 

to the current rating formula, fewer 

veterans would be rated at or below 50 

percent disability and more would be 

rated above 50 percent under the 

proposed criteria. The two formulae 

seemed to yield similar results at 70 

percent disabling, and the number of 

veterans who would receive 100 percent 

disability was greater under the 

proposed criteria than under the current 

criteria. 

Regarding the second objective, 

adjudicators reported that the revised 

Mental Disorders DBQ provided all the 

information they needed to evaluate 

based on the proposed criteria. 

Regarding the third objective, 

adjudicators reported that they were 

easily able to extract rating data from 

the revised DBQ and apply new 

evaluation criteria. Finally, C&P 

examiners reported that the revised 

DBQ was adequate and easy to use in a 

clinical setting. 

Importantly, one major theme in the 

feedback regarding mental disorders has 

been the need for a common language in 

the VASRD—a language familiar to both 

clinicians and adjudicators. According 

to the proof-of-concept study results, 

VA achieved this objective with the 

proposed General Rating Formula for 

Mental Disorders. 

VI. Notes to the Proposed General 

Rating Formula 

VA proposes to add three notes at the 

end of the General Rating Formula for 

Mental Disorders to promote greater 

consistency and accuracy in applying 

the criteria. 

The first note would provide that only 

one evaluation will be assigned for coexisting service-connected mental 

disorders. According to 38 U.S.C. 1155, 

the VA rating schedule shall 

compensate veterans for ‘‘impairments 

of earning capacity,’’ not specific 

diagnoses. And according to 38 CFR 

4.14, evaluations of the same disability 

or manifestation under different 

diagnoses is to be avoided. Most mental 

disorders are ‘‘composed of multiple 

emotional, cognitive, and behavioral 

dimensions, many of which are shared 

across disorders.’’ Lee Ann Clark et al., 

‘‘Three Approaches to Understanding 

and Classifying Mental Disorder: ICD– 

11, DSM–5, and the National Institute of 

Mental Health’s Research Domain 

Criteria (RDoC),’’ 18 Psychol. Sci. in the 

Pub. Int. 72, 112 (2017). In addition, coexisting mental disorders, that is, 

comorbidity, ‘‘is the rule rather than the 

exception.’’ Id. Therefore, consistent 

with 38 U.S.C. 1155 and the rule against 

pyramiding, 38 CFR 4.14, Note (1) will 

instruct adjudicators not to assign 

individual disability ratings to more 

than one mental disorder given the 

likelihood of comorbid mental disorders 

and the prevalence of overlapping 

symptoms among such disorders. 

The second note would explain that 

evaluations under the General Rating 

Formula for Mental Disorders would 

consider any ameliorating effects of 

medications prescribed for a mental 

disorder. In other words, if a veteran 

were receiving medication for a mental 

disability, VA would rate only the 

disabling symptomatology that exists 

after the ameliorative effects of 

medication are taken into account. We 

are adding this note because in Jones v. 

Shinseki, 26 Vet. App. 56, 63 (2012), the 

United States Court of Appeals for 

Veterans Claims held that, ‘‘[a]bsent a 

clear statement [in the rating criteria] 

setting out whether or how the Board [of 

Veterans’ Appeals (Board)] should 

address the effects of medication,’’ the 

Board should not take those effects into 

account when evaluating a claimant’s 

disability. However, consideration of 

ameliorating effects of medications is 

consistent with 38 CFR 4.2, which states 

that VA adjudicators should consider a 

disability ‘‘from the point of view of the 

veteran working or seeking work’’ and 

provide a current rating that ‘‘accurately 

reflect[s] the elements of disability 

present.’’ VA adjudicators should not be 

basing ratings on speculation of how 

severe a veteran’s disability might be if 

he or she were not taking medication; 

the rating should be based on the actual 

elements of disability present. See 

generally McCarroll v. McDonald, 28 

Vet. App. 267, 276–78 (2016) (Kasold, J., 

concurring in part). 

The third note would explain that, in 

evaluating frequency, VA adjudicators 

should consider the percentage of time, 

in a given month, that impairment 

occurs. As discussed above, this is 

consistent with the WHO’s ICF 

Checklist rate. VA seeks comment on 

the three proposed notes. 

VII. Technical Amendments 

Finally, VA proposes to update 

Appendix A of part 4 to reflect the 

above proposed amendments to the 

rating schedule for mental disorders. 

Executive Orders 12866 and 13563 

Executive Orders 12866 and 13563 

direct agencies to assess the costs and 

benefits of available regulatory 

alternatives and, when regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, and other advantages; 

distributive impacts; and equity). 

Executive Order 13563 (Improving 

Regulation and Regulatory Review) 


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emphasizes the importance of 

quantifying both costs and benefits, 

reducing costs, harmonizing rules, and 

promoting flexibility. The Office of 

Information and Regulatory Affairs has 

determined that this rule is an 

economically significant regulatory 

action under Executive Order 12866. 

The Regulatory Impact Analysis 

associated with this rulemaking can be 

found as a supporting document at 

www.regulations.gov. 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this rulemaking will not have a 

significant economic impact on a 

substantial number of small entities as 

they are defined in the Regulatory 

Flexibility Act (5 U.S.C. 601–612). The 

certification is based on the fact that no 

small entities or businesses would be 

subject to the rating criteria revisions or 

assign evaluations for disability claims. 

Therefore, pursuant to 5 U.S.C. 605(b), 

the initial and final regulatory flexibility 

analysis requirements of 5 U.S.C. 603 

and 604 do not apply. 

Unfunded Mandates 

The Unfunded Mandates Reform Act 

of 1995 requires, at 2 U.S.C. 1532, that 

agencies prepare an assessment of 

anticipated costs and benefits before 

issuing any rule that may result in the 

expenditure by State, local, and tribal 

governments, in the aggregate, or by the 

private sector, of $100 million or more 

(adjusted annually for inflation) in any 

given year. This proposed rule would 

have no such effect on State, local, and 

tribal governments, or on the private 

sector. 

Paperwork Reduction Act 

This proposed rule contains no 

provisions constituting a collection of 

information under the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501– 

3521). 

Assistance Listing 

The Assistance Listing numbers and 

titles for this rule are 64.104, Pension 

for Non-Service-Connected Disability 

for Veterans; 64.109, Veterans 

Compensation for Service-Connected 

Disability; and 64.110, Veterans 

Dependency and Indemnity 

Compensation for Service-Connected 

Death. 

List of Subjects in 38 CFR Part 4 

Disability benefits, Pensions, 

Veterans. 

Signing Authority 

Denis McDonough, Secretary of 

Veterans Affairs, approved this 

document on July 9, 2021 and 

authorized the undersigned to sign and 

submit the document to the Office of the 

Federal Register for publication 

electronically as an official document of 

the Department of Veterans Affairs. 

Michael P. Shores, 

Director, Office of Regulation Policy & 

Management, Office of the Secretary, 

Department of Veterans Affairs. 

For the reasons set out in the 

preamble, VA proposes to amend 38 

CFR part 4, subpart B as set forth below: 

Part 4—SCHEDULE FOR RATING 

DISABILITIES 

■ 1. The authority citation for part 4 

continues to read as follows: 

Authority: 38 U.S.C. 1155, unless 

otherwise noted. 

■ 2. Amend § 4.126 by: 

■ a. Revising paragraph (a); 

■ b. Removing paragraph (b); and 

■ c. Redesignating paragraphs (c) and 

(d) as paragraphs (b) and (c). 

The revisions read as follows: 

§ 4.126 Evaluations of disability from 

mental disorders. 

(a) When evaluating a mental 

disorder, the rating agency shall 

consider all the evidence of record 

relevant to the intensity and frequency 

of psychiatric symptoms that bear on 

the following domains (major areas of 

functioning): 

(1) Cognition (i.e., understanding and 

communicating); 

(2) interpersonal interactions and 

relationships (i.e., interacting with 

people and participating in society); 

(3) task completion and life activities; 

(4) navigating environments (i.e., 

getting around); and 

(5) self-care. 

The rating agency shall assess the 

intensity and frequency of symptoms in 

each domain and assign an evaluation 

based on the combined levels of 

functioning in these domains as 

explained in section 4.130. 

* * * * * 

■ 3. Amend § 4.130 by: 

■ a. Republishing the entry for 

diagnostic code (DC) 9440; 

■ b. Adding immediately following (DC) 

9440, the entries for (DCs) 9520 and 

9521; 

■ c. Revising the table ‘‘General Rating 

Formula for Mental Disorders’’; 

■ d. Removing immediately following 

the table ‘‘General Rating Formula for 

Mental Disorders’’ the entries for (DCs) 

9520 and 9521; and 

■ e. Removing the table ‘‘Rating 

Formula for Eating Disorders’’. 

The additions and revisions read as 

follows: 

§ 4.130 Schedule of ratings—Mental 

disorders. 

* * * * * 

9440 Chronic adjustment disorder 

9520 Anorexia nervosa 

9521 Bulimia nervosa 

GENERAL RATING FORMULA FOR MENTAL DISORDERS

Rating 

The General Rating Formula for Mental Disorders contains five domains related to function: Cognition; interpersonal interactions 

and relationships; task completion and life activities; navigating environments; and self-care. The criteria below describe each 

domain.

The General Rating Formula for Mental Disorders provides criteria for each domain for levels of function ranging from 0 to 4, as 

appropriate. The highest level of impairment, a score of 4, signifies ‘‘total,’’ and the lowest level of impairment, a score of 0, 

signifies ‘‘no difficulties.’’ 

Evaluate based on the level of impairment in each domain and the number of affected domains, as follows: 

Level 4 in one or more domains, or Level 3 in two or more domains ........................................................................................ 100 

Level 3 in one domain, or Level 2 in two or more domains ........................................................................................................ 70 

Level 2 in one domain .................................................................................................................................................................. 50 

Level 1 in two or more domains ................................................................................................................................................... 30 

Minimum rating ............................................................................................................................................................................. 10 

Note (1): Coexisting mental disorders cannot receive distinct and separate disability evaluations without violating the anti-pyramiding regulation 

of § 4.14. Therefore, assign a single evaluation reflecting all impairment due to coexisting service-connected mental disorders using the General 

Rating Formula in this section. 

Note (2): Include any ameliorating effects of medications when evaluating the extent of disability under the General Rating Formula in this section. 


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Note (3): In evaluating frequency of impairment, consider the percentage of time, in a given month, that impairment occurs. 

Domain Level of impairment Criteria 

1. Cognition: May include, but is not limited to, memory, concentration, attention, goal setting, speed of processing information, planning, 

organizing, prioritizing, problem solving, judgment, making decisions, or flexibility in adapting when appropriate. 

0 = None ..................................................................................... No difficulties: Cognitive functioning intact. 

1 = Mild impairment at any frequency; or moderate impairment 

that occurs less than 25% of the time.

Mild: Slight difficulties in one or more aspects of cognitive 

functioning that do not interfere with tasks, activities, or relationships. 

2 = Moderate impairment that occurs 25% or more of the time; 

or severe impairment that occurs less than 25% of the time.

Moderate: Clinically significant difficulties in one or more aspects of cognitive functioning that interfere with tasks, activities, or relationships. 

3 = Severe impairment that occurs 25% or more of the time; or 

total impairment that occurs less than 25% of the time.

Severe: Serious difficulties in one or more aspects of cognitive 

functioning that interfere with tasks, activities, or relationships. 

4 = Total impairment that occurs 25% or more of the time ....... Total: Profound difficulties in one or more aspects of cognitive

functioning that cannot be managed or remediated; incapable of even the most basic tasks within one or more aspects 

of cognitive functioning; difficulties that completely interfere 

with tasks, activities, or relationships. 

2. Interpersonal interactions and relationships: Includes both informal (social, associational, etc.) and formal (coworkers, supervisors, etc.). 

0 = None. .................................................................................... No difficulties: Individual able to have relationships and interact 

with others at work, school, and other contexts. 

1 = Mild impairment at any frequency; or moderate impairment 

that occurs less than 25% of the time.

Mild: Slight difficulties in one or more aspects of interpersonal 

functioning that do not interfere with tasks, activities, or relationships. 

2 = Moderate impairment that occurs 25% or more of the time; 

or severe impairment that occurs less than 25% of the time.

Moderate: Clinically significant difficulties in one or more aspects of interpersonal functioning that interfere with tasks, 

activities, or relationships. 

3 = Severe impairment that occurs 25% or more of the time; or 

total impairment that occurs less than 25% of the time.

Severe: Serious difficulties in one or more aspects of interpersonal functioning that interfere with tasks, activities, or relationships, even with accommodations or assistance. 

4 = Total impairment that occurs 25% or more of the time ....... Total: Profound difficulties in one or more aspects of interpersonal functioning that cannot be managed or remediated; 

incapable of even the most basic tasks within one or more 

aspects of relationships; difficulties that completely interfere 

with tasks, activities, or relationships. 

3. Task completion and life activities: May include, but are not limited to, the following types of activities: Vocational, educational, domestic, 

social, or caregiving. 

0 = None ..................................................................................... No difficulties: Individual able to perform tasks and participate 

in life activities; needs no accommodations or assistance. 

1 = Mild impairment at any frequency; or moderate impairment 

that occurs less than 25% of the time.

Mild: Slight difficulties in one or more aspects of task completion or life activities that were completed with minor stress or 

minor accommodations. 

2 = Moderate impairment that occurs 25% or more of the time; 

or severe impairment that occurs less than 25% of the time.

Moderate: Clinically significant difficulties in one or more aspects of task completion or life activities that were completed with significant stress or accommodations. 

3 = Severe impairment that occurs 25% or more of the time; or 

total impairment that occurs less than 25% of the time.

Severe: Serious difficulties in two or more aspects of task 

completion or life activities that were completed with significant stress and accommodations. 

4 = Total impairment that occurs 25% or more of the time ....... Total: Profound difficulties in two or more aspects of task completion or life activities, one of which must be vocational, 

that were not completed even with considerable accommodations due to overwhelming stress; incapable of even 

the most basic tasks within one or more aspects of task 

completion or life activities. 

4. Navigating environments: May include, but is not limited to, the following: Leaving the home, being in confined or crowded spaces, 

independently moving in surroundings, navigating new environments, driving, or using public transportation. 

0 = None. .................................................................................... No difficulties: Capability to navigate environments intact. 

1 = Mild impairment at any frequency; or moderate impairment 

that occurs less than 25% of the time.

Mild: Slight difficulties in one or more aspects of navigating environments that do not interfere with tasks, activities, or relationships. 

2 = Moderate impairment that occurs 25% or more of the time; 

or severe impairment that occurs less than 25% of the time.

Moderate: Clinically significant difficulties in one or more aspects of navigating environments that interfere with tasks, 

activities, or relationships. 

3 = Severe impairment that occurs 25% or more of the time; or 

total impairment that occurs less than 25% of the time.

Severe: Serious difficulties in one or more areas of navigating 

environments that interfere with tasks, activities, or relationships, even with accommodations or assistance. 


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Domain Level of impairment Criteria 

4 = Total impairment that occurs 25% or more of the time ....... Total: Profound difficulties in one or more aspects of navigating environments that cannot be managed or remediated; 

incapable of even the most basic tasks within one or more 

aspects of environmental navigation; difficulties that completely interfere with tasks, activities, or relationships. 

5. Self-care: May include, but is not limited to, the following types of activities: Hygiene, dressing appropriately, or taking nourishment. 

0 = None ..................................................................................... No difficulties: Self-care capabilities intact. 

1 = Mild impairment at any frequency; or moderate impairment 

that occurs less than 25% of the time.

Mild: Slight difficulties in one or more aspects of self-care that 

do not interfere with tasks, activities, or relationships. 

2 = Moderate impairment that occurs 25% or more of the time; 

or severe impairment that occurs less than 25% of the time.

Moderate: Clinically significant difficulties in one or more aspects of self-care that interfere with tasks, activities, or relationships without accommodations or assistance. 

3 = Severe impairment that occurs 25% or more of the time; or 

total impairment that occurs less than 25% of the time.

Severe: Serious difficulties in one or more aspects of self-care 

that interfere with tasks, activities, or relationships, even with 

accommodations or assistance. 

4 = Total impairment that occurs 25% or more of the time ....... Total: Profound difficulties in one or more aspects of self-care

that cannot be managed or remediated; difficulties that completely interfere with tasks, activities, or relationships, even 

with accommodations or assistance. 

■ 4. Amend Appendix A to part 4, 

§ 4.130, to read as follows: 

Appendix A to Part 4—Table of 

Amendments and Effective Dates Since 

1946 

Sec. Diagnostic 

code No. 

*******

4.130 .............................. ........................ Re-designated from § 4.132 November 7, 1996; General Rating Formula for Mental Disorders revision [Effective date of final rule]. 

9520 Added November 7, 1996; criterion [Effective date of final rule]. 

9521 Added November 7, 1996; criterion [Effective date of final rule]. 

*******

(Authority: 38 U.S.C. 1155) 

[FR Doc. 2022–02051 Filed 2–14–22; 8:45 am] 

BILLING CODE 8320–01–P 

FEDERAL MARITIME COMMISSION 

46 CFR Chapter IV, Subchapter B 

[Docket No. 22–04] 

RIN 3072–AC90 

Demurrage and Detention Billing 

Requirements 

AGENCY: Federal Maritime Commission. 

ACTION: Advance Notice of Proposed 

Rulemaking. 

SUMMARY: The Federal Maritime 

Commission (Commission) is issuing 

this Advance Notice of Proposed 

Rulemaking (ANPRM) to seek comment 

on whether the Commission should 

require common carriers and marine 

terminal operators to include certain 

minimum information on or with 

demurrage and detention billings. Also, 

the Commission is interested in 

receiving comments on whether it 

should require common carriers and 

marine terminal operators to adhere to 

certain practices regarding the timing of 

demurrage and detention billings. These 

changes were recommended by the Fact 

Finding Officer in Commission Fact 

Finding 29: International Ocean 

Transportation Supply Chain 

Engagement. 

DATES: Submit comments on or before 

March 17, 2022. 

ADDRESSES: You may submit comments, 

identified by Docket No. 22–04, by 

email at secretary@fmc.gov. For 

comments, include in the subject line: 

‘‘Docket No. 22–04, Comments on 

Demurrage and Detention Billing 

Requirements ANPRM.’’ Comments 

should be attached to the email as a 

Microsoft Word or text-searchable PDF 

document. Only non-confidential and 

public versions of confidential 

comments should be submitted by 

email. 

Instructions: For detailed instructions 

on submitting comments, including 

requesting confidential treatment of 

comments, and additional information 

on the rulemaking process, see the 

Public Participation heading of the 

Supplementary Information section of 

this document. Note that all comments 

received will be posted without change 

to the Commission’s website unless the 

commenter has requested confidential 

treatment. 

Docket: For access to the docket to 

read background documents or 

comments received, go to the 

Commission’s Electronic Reading Room 

at: https://www2.fmc.gov/readingroom/ 

proceeding/22-04. 

FOR FURTHER INFORMATION CONTACT: 

William Cody, Secretary; Phone: (202) 

523–5725; Email: secretary@fmc.gov. 

SUPPLEMENTARY INFORMATION: 

I. Public Participation 

How do I prepare and submit 

comments? 

Your comments must be written in 

English. To ensure that your comments 

are correctly filed in the docket, please 

include the docket number of this 

document in your comments. 


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