a. When Multiple Disabilities Should Not Be Evaluated as a Single Disability Do not rate multiple disabilities as a single disability if there is a possibility of entitlement to SMC under , or an intermediate or next higher rate of SMC , or . b. Evaluating a Multisystem Disorder The assignment of a single evaluation of 100 percent for a multisystem disorder, based on LOU of two extremities, may overlook the disorder’s involvement in other body systems. This involvement might meet requirements for an intermediate rate under , or the next higher rate . c. Example: Rating Decision Involving a Multisystem Disorder Situation: A Veteran has lost the use of both lower extremities due to SC multiple sclerosis. Result: Assign a 100-percent evaluation for the LOU of both lower extremities under hyphenated diagnostic code (DC) 8018-5110, and separate evaluations under the appropriate DCs for the involvement of any other body system so that possible entitlement to a higher level of SMC will not be overlooked. Coded Conclusion: Assume the disabilities shown below are all related to multiple sclerosis. SUBJECT TO COMPENSATION (1.SC) 8018-5110 MULTIPLE SCLEROSIS, WITH LOSS OF USE BOTH LOWER EXTREMITIES 100 percent from 06/14/1996. 6516 DYSARTHRIA, DUE TO MULTIPLE SCLEROSIS 30 percent from 06/14/1996. 7332 IMPAIRMENT OF ANAL SPHINCTER CONTROL DUE TO MULTIPLE SCLEROSIS 10 percent from 06/14/1996. 7512 LOSS OF BLADDER CONTROL, MODERATE, DUE TO MULTIPLE SCLEROSIS 10 percent from 06/14/1996. 6016 NYSTAGMUS DUE TO MULTIPLE SCLEROSIS
3. Hospital Adjustments Under 38 CFR 3.552 Introduction This topic contains information on hospital adjustments under 38 CFR 3.552, including specifying the basis of entitlement under 38 CFR 3.552 in the rating decision the consequences of an improperly assigned SMC hospital code, and examples of rating decisions with properly assigned SMC hospital codes. Change Date June 16, 2015 a. Specifying the Basis of Entitlement Under 38 CFR 3.552 in the Rating Decision The rating decision must specify the basis of the Veteran’s entitlement to a hospital adjustment in order to ensure the proper application of . The SMC allowance for A&A must be discontinued during hospitalization at government expense, unless the need for A&A is due to paraplegia involving paralysis of both lower extremities, together with loss of anal and bladder sphincter control, or Hansen’s disease. Exception: The SMC allowance for A&A must be discontinued during hospitalization, regardless of the disability involved, if entitlement is established under , or . Note: Regardless of pre-existing paraplegia, SMC is payable at the rate prescribed in to a claimant who is entitled to compensation for bilateral disarticulation of the hips per . References: For more information on entitlement to a higher A&A allowance under , see M21-1, Part IV, Subpart ii, 2.H.9, and , see M21-1, Part IV, Subpart ii, 2.H.11. b. Consequences The assignment of an improper SMC hospital code may result in erroneous adjustment of the Veteran’s award upon hospitalization.
g. Awarding SMC for LOU of Both Buttocks Award SMC for LOU of both buttocks when there is severe damage by disease or injury to muscle group XVII (the gluteus maximus, gluteus medius, and gluteus minimus), bilaterally, which renders the Veteran unable to complete the following actions rise from a seated or stooped position, and maintain postural stability. Note: Assistance performing the physical actions listed includes the use of the person’s own hands or arms and a special appliance for postural stability. Reference: For more information on LOU of the buttocks, see . h. Awarding SMC for Deafness Award SMC for deafness of both ears, having absence of air and bone conduction, if the SC bilateral hearing loss warrants a 100-percent evaluation under the evaluation criteria in and for hearing impairment. A Veteran with bilateral SC hearing impairment, numerically designated as XI, is entitled to SMC, regardless of whether or not measurable hearing impairment was noted on entrance into service and SC was awarded based on aggravation of a pre-existing disability. Notes: A numeric designation of hearing impairment of XI in both ears entitles the Veteran to SMC, and less than XI in either ear precludes entitlement to SMC. Base disability ratings only on an examination conducted in a audiology clinic using current testing criteria. Hearing loss justifying an award of SMC must be permanent in nature. i. Awarding SMC for Complete Organic Aphonia Award SMC for complete organic aphonia if a disability of the organs of speech exists that constantly precludes communication by speech and the Veteran is unable to communicate by voice or whisper through the normal organs of speech, and the disability is constant and of organic origin. Notes: Complete organic aphonia most frequently results from loss or paralysis of an organ of speech such as the tongue or larynx. The use of other organs of the body or prosthetic devices to provide voice sounds does not preclude entitlement to SMC. The assignment of total schedular ratings under , and , generally entitles the Veteran to SMC. authorized
j. Awarding SMC for LOU or Blindness of One Eye SMC for LOU or blindness of one eye, having LPO, when the Veteran is unable to recognize test letters at one foot, and recognize objects, hand movements, or fingers at a distance of three feet. Note: SMC is also payable for the anatomical loss of an eye. k. Awarding SMC for Loss of Breast Tissue Entitlement to SMC for loss of tissue from one or both breasts is limited to female Veterans. PL 107-330, enacted December 6, 2002, provides for the payment of SMC for loss of 25-percent or more of the tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy), or when breast tissue has been subjected to radiation treatment. Note: Before enactment of PL 107-330, entitlement to SMC existed only upon complete surgical removal of breast tissue (or the equivalent loss of breast tissue due to injury), included radical mastectomy, modified radical mastectomy, and simple (or total) mastectomy. Reference: For more information on entitlement to SMC for loss of breast tissue, see . 5. SMC for Blindness With Other Disabilities Affecting Hearing and the Extremities
f. Example 1: Rating Decision Involving SMC for Total SC Deafness in One Ear and Bilateral Blindness Situation: The Veteran has bilateral SC blindness with LPO, and total SC hearing loss in the left ear no separate and distinct disability evaluated as 100-percent disabling, and no separate and distinct disability evaluated as 50-percent disabling. Result: Since the Veteran has LPO bilaterally, and total SC loss of hearing in the left ear, entitlement to SMC is warranted under , and . Coded Conclusion: The appropriate SMC paragraph code is OB-2. The appropriate SMC coding is 37-37-21-00-0. g. Example 2: Rating Decision Involving SMC for Total SC Deafness in One Ear and Bilateral Blindness Situation: The Veteran has bilateral SC blindness with no light perception (NLP) in the left eye, and visual acuity of 5/200 (1.5/60) in the right eye total SC hearing loss in the left ear no separate and distinct disability evaluated as 100-percent disabling, and no separate and distinct disability evaluated as 50-percent disabling. Result: The Veteran is entitled to SMC under for the degree of bilateral blindness alone, but an additional one-half step in the level of SMC (“m½”) is warranted, based on the degree of hearing loss, under the provisions of . Coded Conclusion: The appropriate SMC paragraph code is PB-1. The appropriate SMC coding is 20-20-21-00-0. h. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10 or 20-Percent Disabling A Veteran is entitled to an additional one-half step in the level of SMC under if he/she has SC bilateral blindness with LPO or less bilateral hearing loss, considered 10-or 20-percent disabling, and SC hearing loss in at least one ear. Note: If visual acuity in either of the eyes is better than LPO, entitlement to the additional one-half step does not exist.
Hearing Loss Considered Disabling no separate and distinct disability evaluated as 50-percent disabling. Result: The Veteran is entitled to SMC under the provisions of for the degree of blindness alone. However, an additional full step is warranted under the provisions of , thereby entitling the Veteran to SMC under . Conclusion: The appropriate SMC paragraph code is PB-3. The appropriate SMC coding is 21-21-11-11-0. m. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered Disabling A Veteran is entitled to SMC under and if he/she has blindness with LPO or less in both eyes, and bilateral hearing loss, considered at least 40-percent disabling, or SC hearing loss in at least one ear. Note: If bilateral blindness is present, but visual acuity in either eye is better than LPO, the Veteran is entitled to an additional full step only in the level of SMC, not to exceed that provided by , per n. Example 1: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered Disabling Situation: The Veteran has NLP in the right eye LPO in the left eye SC bilateral hearing loss evaluated as 40-percent disabling no total hearing loss in either ear no separate and distinct disability evaluated as 100-percent disabling, and no separate and distinct disability evaluated as 50-percent disabling. Result: The appropriate level of SMC for the degree of bilateral blindness alone is “m ½.” However, apply because of the coexisting hearing loss. The Veteran is accordingly entitled to SMC under . Coded Conclusion: The appropriate SMC paragraph code is OB-2. The appropriate SMC coding is 37-37-21-00-0. o. Example 2: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered Disabling Situation: The Veteran has NLP in the right eye visual acuity of 5/200 (1.5/60) in the left eye SC bilateral hearing loss, evaluated as 40-percent disabling no total hearing loss in either ear no separate and distinct disability evaluated as 100-percent disabling, and no separate and distinct disability evaluated as 50-percent disabling. Percent Percent
Result: The Veteran is entitled to SMC under for the degree of bilateral blindness alone. However, because of the degree of hearing loss present, increase the level of SMC by a full step under the provisions of and award SMC under . Coded Conclusion: The appropriate SMC paragraph code is PB-3. The appropriate SMC coding is 21-21-21-00-0. p. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered Disabling A Veteran is entitled to SMC under and if he/she has visual acuity of 20/200 (6/60), bilaterally visual acuity of 20/200 (6/60) in one eye and LPO or less in the other eye LPO bilateral hearing loss, considered at 60-percent disabling, and SC hearing loss in one ear. q. Example: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered Disabling Situation: The Veteran has LPO in the right eye visual acuity of 20/200 (6/60) in the left eye SC bilateral hearing loss, evaluated as 60-percent disabling no total hearing loss in either ear no separate and distinct disability evaluated as 100-percent disabling no separate and distinct disability evaluated as 50-percent disabling, and no entitlement to A&A. Result: Due to the coexisting blindness and hearing loss, the Veteran is entitled to SMC under and Coded Conclusion: The appropriate SMC paragraph code is OB-1. The appropriate SMC coding is 37-37-21-00-0. r. SMC for Bilateral Blindness With L/LOU of an Extremity Considered at Least 50 Disabling The provisions of and for an additional full step of SMC, not to exceed entitlement under , if the Veteran has visual acuity of 5/200 (1.5/60) or less, bilaterally, and SC L/LOU of an upper or lower extremity, which by itself or in combination with another compensable disability is considered at least disabling. Note: Payment of this additional full step of SMC is in addition to the SMC payable under