Citation Nr: 1127833 Decision Date: 07/26/11 Archive Date: 08/02/11 DOCKET NO. 10-10 753 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for service-connected post traumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of shell fragment wound to the right upper chest. 3. Entitlement to a compensable disability rating for service-connected residuals of a shell fragment wound to the abdominal wall. 4. Entitlement to a compensable disability rating for service-connected residuals of shell fragment wound to the left axillary region. REPRESENTATION Veteran represented by: AMVETS ATTORNEY FOR THE BOARD James Alsup, Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1969. Service in Vietnam and award of the Combat Infantry Badge and Purple Heart Medal are evidenced in the record. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran's March 2006 claim for an increased disability rating for service-connected PTSD was denied in a June 2006 rating decision. The Veteran disagreed and perfected an appeal. The Veteran's September 2008 claim for increased disability ratings for residuals of shell fragment wounds was denied in a November 2008 rating decision. The Veteran disagreed and perfected an appeal. FINDINGS OF FACT 1. The Veteran's service-connected PTSD is manifested by complaints of difficulty concentrating and focusing; irritability and angry outbursts; intrusive memories of combat; hypervigilance and overly alert; lack of friends and difficulty maintaining effective relationships. 2. The Veteran's service-connected residuals of shell fragment wound to the right upper chest is manifested by a scar that is nontender, superficial, without inflammation, edema or keloid formation, and is "moderately adherent to the underlying tissues," without evidence of skin breakdown or that causes limitation of motion or function. 3. The Veteran's service-connected residuals of a shell fragment wound to the abdominal wall is manifested by a superficial, nontender and nonadherent scar without areas of skin breakdown which does not limit motion or affect function, and without evidence of edema, inflammation or keloid formation. 4. The Veteran's service-connected residuals of shell fragment wound to the left axillary region is manifested by a scar described as invisible and without tenderness. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for service-connected PTSD have been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 4.30, Diagnostic Code 9411 (2010). 2. The criteria for a disability rating in excess of 10 percent for service-connected residuals of shell fragment wound to the right upper chest have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes7804, 7805 (2008; 2010). 3. The criteria for a compensable disability rating for service-connected residuals of a shell fragment wound to the abdominal wall have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008-2010). 4. The criteria for a compensable disability rating for service-connected residuals of shell fragment wound to the left axillary region have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008-2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran generally contends that he is entitled to higher disability ratings for his service-connected disabilities. The Board will first address preliminary matters and then render decisions on the issues on appeal. Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The RO informed the Veteran in notice letters dated August 2006 and September 2008 about the information and evidence that is necessary to substantiate his claims for increased ratings. Specifically, the letters stated that the evidence must show that his service connected disabilities have increased in severity. Additionally, the statements of the case (SOCs) notified the Veteran of the reasons for the denial of his application and, in so doing, informed him of the evidence that was needed to substantiate his claim. In addition, the RO notified the Veteran in that reasonable efforts would be made to help him obtain evidence necessary to support his claim, including that VA would request any pertinent records held by Federal agencies, such as military records, and VA medical records. The Veteran was also informed that a medical examination would be provided or that a medical opinion would be obtained if it was determined that such evidence was necessary to make a decision on his claim. Finally, the letters informed the Veteran of how VA determines a disability rating and an effective date. The Veteran's service medical records as well as all available VA treatment records are in the claims file and were reviewed by both the RO and the Board in connection with his claim. He was also afforded VA examinations in May 2006, February and October 2008, and June 2010 in connection with his claims for increased ratings for PTSD and residuals of shell fragment wounds. VA has further assisted the Veteran and his representative throughout the course of this appeal by providing them with SOCs, which informed them of the laws and regulations relevant to the Veteran's claim. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2010). The record reveals that the Veteran waived his right to a hearing before a local hearing officer and did not seek a hearing before a Veterans Law Judge. See VA Form-9 submissions dated May 2008 and March 2010. The Board will therefore proceed to a decision on the merits. Entitlement to a disability rating in excess of 30 percent for service-connected PTSD. Relevant law and regulations Increased ratings - in general Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2010). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2010). Assignment of diagnostic code The Veteran's service-connected PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 [PTSD] and is currently evaluated as 30 percent disabling. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 9411 is deemed by the Board to be the most appropriate primarily because it pertains specifically to the primary diagnosed disability in the Veteran's case (PTSD). The Board can identify nothing in the evidence to suggest that another diagnostic code would be more appropriate, and the Veteran has not requested that another diagnostic code be used. In any event, all psychiatric disabilities, except eating disorders, are rating using identical schedular criteria. Accordingly, the Board concludes that the veteran is appropriately rated under Diagnostic Code 9411. Specific schedular criteria Under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010), a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Global Assessment of Functioning Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging from 71 to 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130. Analysis The Veteran contends that his PTSD is worse than characterized by the currently assigned 30 percent disability rating and maintains that he is entitled to a 70 percent disability rating for his PTSD. See for example June 2010 VA psychiatric examiner's report. For the following reasons, the Board finds that the Veteran's service-connected PTSD is best portrayed by the criteria of a 50 percent disability rating. The Veteran's medical evidence includes VA examinations dated May 2006, February 2008 and June 2010. All examinations were completed by VA psychologists. There is no record that the Veteran received mental health treatment at VA or any other location during the pendency of the claim, with the exception of his attendance at classes for Veterans with PTSD. The May 2006 examiner reported that they examined the Veteran's VA claims folder. The Veteran complained that he could not focus as well as in the past and that he had recently been laid off for 3 days from his job because he had made a mistake that he attributed to his poor concentration. He also told the examiner that he had been laid off for an additional 3 days for assaulting a coworker. The Veteran told the examiner that he was not getting along with his wife and two older children, and that he had no friends. He related that he had daily memories of Vietnam and had "flashbacks" and nightmares of events that took place in Vietnam or were related to Vietnam. He stated that he avoided anything that reminded him of Vietnam and considered himself to be in social isolation. He noted he had sleep disturbances, was easily startled and was overly alert and irritable. The examiner administered the Mississippi scale for PTSD and the Beck depression test. The Veteran scored a higher score than he had in 2004 and the examiner noted that it implied "a significant increase in symptoms in approximately a year and a half." The depression test showed the Veteran was "extremely depressed." The examiner reported the Veteran was well groomed and cooperative and had appropriate hygiene. His impulse control was described as appropriate and his speech was normal. The Veteran was oriented to time, place and person, and denied any suicidal or homicidal ideation. His affect was constricted. The examiner noted no perceptual distortion and did not note any psychotic symptoms. The Veteran's thought content was rational and logical, and his thought process was "sequential and goal directed." The Veteran's judgment and insight were deemed to be intact, and his memory was thought to be impaired by "poor concentration. The Veteran stated he was not always depressed, but was depressed "because he can't do anything about PTSD." The May 2006 examiner provided a GAF score of 55. The report of a February 2008 VA psychologist is also of record. The February 2008 examiner did not have the Veteran's VA claims folder, but they did report reviewing the Veteran's September 2004 and May 2006 examination reports along with the various tests that were administered. The February 2008 examiner noted that the Veteran complained of nightmares that occurred about 3 times each week and that he experienced "flashbacks." The examiner observed that it was "unclear whether what [the Veteran] calls flashbacks are in-fact flashbacks." The Veteran stated that he avoided things which initiated memories of combat and that he had sleep and concentration difficulties, and had problems with irritability and angry outbursts. The examiner further noted he was hypervigilant and had exaggerated startle response. The Veteran stated he had no friends and had difficulty communicating with his family. He reported having a sad mood and decreased motivation, and having fleeting thoughts of suicide. The February examiner opined that the Veteran's social and occupational impairment was not "significantly different" from that described in the 2006 examination report. The examiner noted that the Veteran's scores on the Mississippi scale for PTSD and the Beck depression test had increased since the 2006 test results. The examiner, however, also noted that because of the nature of the results, they were unable to comment if the difference in the 2008 scores represented a significant difference from the 2006 scores. The Veteran was described to be neatly groomed and cooperative and having a "euthymic mood" with a congruent affect. The Veteran was oriented to time, place and person, and his thought processes were described to be "clear and goal directed." There was no evidence of perceptual disturbances. The Veteran's speech was described to be "articulate" and normal. The Veteran's attention and concentration were good, his judgment and insight were intact, and his impulse control was normal. The examiner noted that the Veteran's symptoms were of "moderate severity" and that there was "little evidence" of a change from the 2006 examination. The examiner provided a GAF score of 55. The Veteran's VA claims folder also includes a June 2010 psychological report. Again, the examiner stated that the Veteran's VA claims folder was not available, but the prior psychological examination reports were reviewed and his VA medical records were seen. After providing an example of what the Veteran calls a flashback, the examiner reported that the Veteran's "description of flashback is not consistent with DSM IV's description of flashback." The Veteran told the examiner he had no friends, but still was married to the same woman he had been married to for 30 years. He admitted he had anger problems and reported he had an incident in December 2009 when he succumbed to road rage and was close to a physical altercation on the side of the road that was, apparently, stopped by a police officer. That said, however, the examiner observed that the Veteran's anger management had not worsened since the 2008 examination. The Veteran stated that he had quit his job or, as he put it, gone on strike. The reasons for his unemployment were not clearly disclosed other than the Veteran had been "bullied" by a coworker. The Veteran explained he had anger problems with his family, but the examiner again noted there were no changes with the problems the Veteran had with his family from the 2008 examination. The examiner stated the Veteran was appropriately attired and his hygiene was good. His mood was described as "stable" and he reportedly showed a "reactive and full range affect." The Veteran's insight and judgment were described to be "adequate" and he was oriented to time, place and person. The examiner concluded with an opinion that the Veteran was "not having more difficulty or experiencing more or different symptomatology than what he presented at his most recent" examination in 2008. The examiner also noted that the Veteran was capable of working and his occupational impairment was "mild." The examiner reported a GAF score of 65. The Veteran stated in a March 2010 VA-Form 9 that he chose not to go into a group therapy situation because "I don't want to set (sic) around with a bunch of losers who never saw combat and want to talk about the past." He also stated that he gets about 4-to-5 hours of sleep each night and that he had problems concentrating. The June 2010 examiner reported that the Veteran intended to attend a group therapy session. Discussion The Veteran seeks a disability rating in excess of 30 percent. As noted above, the criteria for a 50 percent rating include symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. The Veteran's affect was described in May 2006 as "constricted;" in February 2008 it was described as "euthymic;" and in June 2010 as "reactive and full range." A review of the examinations shows that the Veteran's affect was never described as flattened. The Veteran's speech has been described as normal and articulate and has never been described as circumstantial, circumlocutory or stereotyped. The Veteran has not reported having panic attacks. None of the examiners have reported that the Veteran could not understand or had difficulty in understanding complex commands; indeed, his cognitive thinking was described to be within normal limits in the May 2006 examination report and his thought processes were described as "clear and goal directed" and his "tests of mental control were unimpaired" in the February 2008 report. The examiners have not reported that the Veteran's memory was impaired. The Veteran has consistently reported a lack of motivation and a depressed mood, and test results appear to validate those reports. In addition, he has reported difficulties in his marriage and with his children, and he has recently left his employment because of difficulties dealing with coworkers. In addition, the May 2006 examiner has opined that the Veteran's impairment increased since the 2004 examination report and the February 2008 and June 2010 reports reflect opinions that the Veteran's impairment has essentially remained the same as that found in the May 2006 report. Thus, the collective opinion is that the Veteran's occupational and social impairment is worse than that reported in 2004. Moreover, the test results appear to substantiate an increased impairment, although the February 2008 examiner noted that the difference may not be as substantial as the May 2006 examiner had thought. In sum, although not all of the criteria of the 50 percent disability rating have been shown, the Board finds that the overall increase in symptomatology has been shown. The Board further observes that not all of the 50 percent criteria need to be met. The Board acknowledges that not all of the criteria for a 100 percent disability rating need be met. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) [the specified factors for each incremental rating were examples rather than requirements for a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme]. In addition, the Veteran has reported, and evidently validates hypervigilance and his 30-year marriage appears to survive, but not thrive. The Veteran has also reported an occasional episode of succumbing to road rage, although it appears none have resulted in physical violence. The reported GAF scores are 55 and, most recently, 65. The most recent GAF score is incongruent with the examiner's assessment that the Veteran's impairment has not appreciably changed from the May 2006 examination, but his GAF score is 10 points higher. The Board notes that GAF scores ranging from 51 to 60 reflect more moderate symptoms and moderate difficulty in social and occupational functioning, such as those reported by the Veteran. After review of the entire record, the Board finds that the symptoms and impairment shown in the medical evidence more closely fit with a 50 percent disability rating than a 30 percent disability rating. The Board further finds, however, that award of a higher disability rating is not substantiated in the record evidence. A 70 percent rating is assigned when there is evidence of suicidal ideation, obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, and near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. Evidence of impaired impulse control, spatial disorientation and neglect of personal appearance and hygiene as well as difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships is also required. The evidence of record shows that the Veteran has normal impulse control and he has been consistently oriented to time, place and person. The evidence shows that the Veteran has had a 30 year marriage that may not be exemplary, but the fact is it has lasted over a long period of time. His hygiene and appearance have been normal and appropriate. His speech has been consistently described as normal and never as illogical or irrelevant. There is no evidence he has had persistent suicidal ideation. His behavior has never been described to include as being so impaired as to prevent him from independently or appropriately functioning. The Board finds that the criteria of a 70 percent disability rating are simply not supported by the evidence of record. Similarly, the 100 percent disability rating criteria have not been met. There is no evidence of gross impairment in thought processes or communication; indeed, the evidence shows his thought process is normal. The Veteran has no reported any delusions or hallucinations. His behavior has never been described to be grossly inappropriate; indeed, in describing the singular occasion he was observed by law enforcement during a "road rage" incident, the Veteran's behavior was not so inappropriate that it resulted in arrest. The Veteran has not been described to be in persistent danger of hurting himself or others and, as previously noted, his personal hygiene has never been other than normal. There is no evidence in the record that the Veteran has been disoriented to time or place, and his complaints of concentration problems have not included complaints that he cannot remember names of close relatives or what he has done for a living or that he cannot remember his own name. The Board therefore finds that the criteria of a 100 percent disability rating are not supported by the evidence of record. Additional matter The record includes correspondence from the Veteran received by the Board in November 2010 and January 2011. The statements essentially relate to the Veteran's attendance and completion of a group therapy class for Veterans suffering from PTSD. The statements were not accompanied by a waiver of consideration by the RO. The Board has read the statements and notes that they are essentially redundant to statements already of record and as such, do not constitute new evidence. The Board finds that consideration of the PTSD claim without consideration of the recently received statements does not prejudice the Veteran because they do not include any new substantive evidence of the nature or extent of his PTSD. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of shell fragment wound to the right upper chest. Entitlement to a compensable disability rating for service-connected residuals of a shell fragment wound to the abdominal wall. Entitlement to a compensable disability rating for service-connected residuals of shell fragment wound to the left axillary region. The three shell fragment wound residuals are evaluated under the same legal criteria and will be addressed in the same analysis. The VA examination reports essentially state that the Veteran's shell fragment wound residuals are asymptomatic scars. The scars are evaluated under 38 C.F.R. § 4.118, Diagnostic Code 7805 [Scars, other]. As noted above, the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case," and any change in a diagnostic code by a VA adjudicator must be specifically explained. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran was examined in October 2008 and in June 2010. The VA examiners essentially described the scars as having no symptoms and requiring no treatment. The Veteran has not requested that a different diagnostic code be used. The schedular disability rating criteria for scars is found at 38 U.S.C.A. § 4.118. The criteria of the diagnostic codes found under § 4.118 changed effective 23 October 2008. Prior to 23 October 2008, 38 C.F.R. § 4.118, Diagnostic Code 7805 [Scars, other] required the rating official to rate the scar on limitation of function of the affected part. After 23 October 2008, 38 C.F.R. § 4.118, Diagnostic Code 7805 [Scars, other (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802 and 7804] provides that the rating official evaluate any disabling effects not considered in a disability rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. For the following reasons, the Board finds that Diagnostic Code 7805 is appropriate. Residuals of shell fragment wound to the right upper chest The October 2008 VA examiner reported that the Veteran's right upper chest scar is approximately 4 centimeters long and 1 centimeter wide and x-ray evidence of retained shrapnel at the site, but no palpable foreign objects were detectable at the site. The examiner stated that the scar was noninflamed and nontender, but may be "somewhat adherent to underlying soft tissue." The examiner also stated that "there is a slight depression in the intercostals muscles upon deep palpation, and this causes some mild tenderness." The Veteran's lungs were clear and the Veteran's muscle function was normal. The June 2010 examiner reported that the scar is faded and "its borders cannot be made out." The scar was nontender, superficial, without inflammation, edema or keloid formation, and "moderately adherent to the underlying tissues." The scar has no evidence of skin breakdown, and does not limit motion or function. Under 38 C.F.R. § 4.118, Diagnostic Code 7804 [Scars, superficial, painful on examination] (2006-08), Note (1) states that "a superficial scar is one not associated with underlying soft tissue damage." Prior to 23 October 2008, Diagnostic Code 7804 provided a maximum of a10 percent disability rating. After 23 October 2008, Diagnostic Code 7804 [Scars, unstable or painful] provides a 10 percent disability rating for one scar that is unstable or painful. Higher disability ratings are provided under post-23 October 2008 if the Veteran has three or more unstable or painful scars. Because the medical evidence shows the Veteran has only one such scar, the Board finds that the Veteran is entitled to the 10 percent disability rating, but no more. Residuals of a shell fragment wound to the abdominal wall The October 2008 VA examiner described the Veteran's abdominal residual scar as a 7.5 centimeter surgical scar that was not inflamed, was nontender, and did not affect any muscular defect. The June 2010 examiner described the scar as a surgical scar that has faded and difficult to see. The scar was described to be nontender, nonadherent, without areas of skin breakdown and superficial. The scar was described not to limit motion or affect function, and there was no evidence of edema, inflammation or keloid formation. Essentially, the scar was not painful or unstable. Under 38 C.F.R. § 4.118, there is no diagnostic code that pertains to a superficial and unpainful and stable scar. Because the scar does not limit motion or affect function of any abdominal component, the evidence does not support a finding that any other diagnostic code would be appropriate. For those reasons, the Board finds that there is no compensable disability rating that can be applied to the Veteran's abdominal shell fragment residual. Residuals of shell fragment wound to the left axillary region The October 2008 VA examiner described the left axillary scar as invisible and without tenderness. The examiner also noted that the left axillary wound was "more like a rope burn and did not require any kind of operative procedures." The June 2010 examiner stated that the "scar in the left axilla is nor longer visible," and also related that the Veteran told him the original wound was like a rope burn. The examiner further stated that there is an area that appeared more like "roughened" skin than a scar. As above, the medical evidence shows a nonpainful and stable area that has no visible scar tissue. Under 38 C.F.R. § 4.118, there is no diagnostic code that pertains to a superficial and unpainful and stable scar. Because the scar does not limit motion or affect function of any abdominal component, the evidence does not support a finding that any other diagnostic code would be appropriate. For those reasons, the Board finds that there is no compensable disability rating that can be applied to the Veteran's left axillary shell fragment residual. Hart consideration In Hart v. Mansfield, 21 Vet App. 505 (2007), the Court held that staged ratings are appropriate for an increased rating claims when the factual findings show distinct time periods where the service-connected disabilities exhibited symptoms that would warrant different ratings. The Hart Court further observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. See 38 U.S.C.A. § 5110 (West 2002). Accordingly, the relevant focus for the Veteran's PTSD claim is from November 2002 to the present. The Veteran's PTSD was rated as 30 percent disabling from November 2002 to November 2003, and, as discussed above, 50 percent from the date of the Veteran's claim received in November 2003. The question to be answered by the Board, then, is whether any different rating should be assigned for the Veteran's PTSD claim disabilities now under consideration for any period from November 2002 to the present. As discussed in detail above, the medical evidence showed an increase symptomatology that has justified a 50 percent disability rating from the date of the Veteran's claim to the present. Throughout the period, there were no clinical findings sufficient to justify the assignment of a higher rating. With regard to the scar claims, the period for consideration is from September 2007 to the present. The Veteran's disabilities were rated as 10 percent disabling for the right chest scar and noncompensable for the abdominal and left axillary scars. As discussed above, the medical evidence of record does not show any change in the condition of the scars during the period under consideration. Accordingly, there will be no staged ratings assigned. Extraschedular consideration An extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2008). An exceptional case includes factors such as marked interference with employment or frequent periods of hospitalization that render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). The Court in Thun v. Peake, 22 Vet. App, 111 (2008), provided a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In this case, with respect to the initial inquiry posed by Thun, the Board has not found an exceptional or unusual disability picture with respect to the veteran's service- connected PTSD and scar disabilities. The medical evidence fails to demonstrate that the symptomatology of any of the Veteran's disabilities is of such an extent that application of the ratings schedule would not be appropriate. Accordingly, the Board finds that the veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluations adequately contemplate the Veteran's levels of disability and symptomatology, the second and third questions posed by Thun become moot. Nevertheless, the Board will briefly note that the evidence in this case does not demonstrate any of the factors provided in the "governing norms" such as frequent hospitalization or marked interference with employment. See 38 C.F.R. § 3.321(b)(1). In this case, there is no indication that the Veteran has required frequent hospitalizations for any of his disabilities. In addition, although the Veteran quit his employment, the June 2010 VA examiner determined that the Veteran is capable of securing and following employment. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a 50 percent disability rating effective 13 March 2006 for service-connected PTSD is granted, subject to controlling regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of shell fragment wound to the right upper chest is denied. Entitlement to a compensable disability rating for service-connected residuals of a shell fragment wound to the abdominal wall is denied. Entitlement to a compensable disability rating for service-connected residuals of shell fragment wound to the left axillary region is denied. ____________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs