Citation Nr: 1332706 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 08-08 565 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for a psychiatric disability. 2. Entitlement to an increased rating for the residuals of a shell fragment wound of the abdomen involving muscle group XIX, currently rated 10 percent. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran served on active duty from July 1968 to October 1969. These matters come before the Board of Veterans' Appeals (Board) from July 2006 and March 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, that granted service connection and assigned a 30 percent rating for posttraumatic stress disorder (PTSD) and denied ratings in excess of 10 percent for a lumbar spine disability and the residuals of a shell fragment wound of the abdomen involving muscle group XIX. In August 2009, the Veteran was provided a videoconference hearing before the undersigned Veterans Law Judge. Thereafter, in January 2010, the Board remanded the claims for additional development. In a January 2012 decision, the Board denied the claims for higher ratings for the psychiatric and low back disabilities, and remanded the claim for an increased rating for the residuals of a shell fragment wound of the abdomen. The Veteran appealed that Board decision to the United States Court of Appeals for Veterans Claims. Pursuant to a Joint Motion for Partial Remand, in a September 2012 Order, the Court remanded that part of the Board decision that denied the claim for an initial rating higher than 30 percent for a psychiatric disability for readjudication in accordance with the joint motion. The remainder of that Board decision was left undisturbed. In the remand portion of the January 2012 decision, the Board requested that the Veteran be afforded a VA examination to determine whether his shell fragment wound of the abdomen caused or aggravated any current digestive disorders. The Veteran was provided an examination in January 2012. A March 2012 rating decision granted service connection for hypertrophic gastritis and hiatal hernia as residuals of the shell fragment wound. The issue of entitlement to an initial rating higher than 30 percent for a psychiatric disability is REMANDED to the RO via the Appeals Management Center, in Washington, D.C. FINDINGS OF FACT 1. The Veteran's residuals of a shell fragment wound of the abdomen have been manifested by moderately severe disability of muscle group XIX. 2. The Veteran's residuals of a shell fragment wound of the abdomen have been manifested by deep scars that involve less than 6 square inches (39 square centimeters). CONCLUSION OF LAW The criteria for a 30 percent rating, but not higher, for residuals of a shell fragment wound of the abdomen involving muscle group XIX have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5319 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and his or her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2013); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements apply to all five elements of a service-connection claim, to include Veteran status, existence of a disability, a connection between service and the disability, degree of disability, and effective date of the disability. Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded should be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the duty to notify requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, and general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). In this case, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran was notified in an October 2005 letter of the criteria for establishing an increased rating, the evidence required, and his and VA's respective duties for obtaining evidence. In a May 2006 letter, he was notified of how VA determines disability ratings and effective dates. Those letters addressed all notice elements and predated the initial adjudication by the RO in July 2006. Next, VA has a duty to assist a Veteran in the development of a claim. That duty includes assisting the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2013). In this case, all necessary development has been accomplished and appellate review may proceed. Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service medical records, and post-service reports of VA and private treatment and examination. The Veteran's statements in support of the claim are of record. The Board has carefully reviewed those statements and concludes that no available outstanding evidence has been identified. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the claim. VA provided the Veteran with examinations in March 2006 and February 2008 to determine the nature and severity of his disability. 38 C.F.R. § 3.159(c)(4) (2013). When VA provides an examination, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In January 2010, as the record indicated that the Veteran's disability may have worsened, the Board requested a new examination. He was provided an examination in November 2010. As that examination did not contain an opinion on the relationship between the Veteran's digestive disorders and his shell fragment wound, the Board requested another examination in January 2012. The Veteran was provided an examination later that month. The Board finds that examination report to be thorough and adequate upon which to base a decision on the claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information needed to rate the disability under the applicable rating criteria. The Board finds that no further notice or assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). In order to rate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the veteran is requesting an increased rating for an established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the age and adequacy of examinations. Powell v. West, 13 Vet. App. 31 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis below is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's residuals of a shell fragment wound of the abdomen have been rated 10 percent under Diagnostic Code 5319 for disability of muscle group XIX. 38 C.F.R. § 4.73 (2013). Under that diagnostic code, moderate muscle disability warrants a 10 percent rating, moderately severe muscle disability warrants a 30 percent rating, and severe muscle disability warrants a 50 percent rating. Functions affected by the muscles involved in muscle group XIX include support and compression of the abdominal wall and lower thorax, flexion and lateral motions of the spine, and synergists in strong downward movements of the arm. An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. A through-and-through injury with muscle damage shall be rated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(a),(b) (2013). The cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c) (2013). Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d) (2013). The type of injury associated with a moderate muscle disability is described as being from a through-and-through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. History should include evidence of in-service treatment for the wound, and a record of consistent complaints of one or more cardinal signs and symptoms of muscle disability particularly lower threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue; some loss of deep fascia or muscle substance or impairment of muscle tonus; and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2) (2013). A moderately severe muscle disability comprises a through-and-through or deep open penetrating wound by a small high-velocity missile or a large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There should be a history of hospitalization for a prolonged period for treatment of the wound, with a record of consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating track of missile through one or more muscle groups; and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. 4.56(d)(3) (2013). Severe muscle disability contemplates through-and-through or deep penetrating wounds due to high-velocity missile, or large or multiple low-velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. There should be a history of hospitalization for a prolonged period for treatment of the wound, with consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpable loss of deep fascia or muscle substance, or soft flabby muscles in wound area; and abnormal muscle swelling and hardening in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. 38 C.F.R. 4.56(d)(4) (2013). If present, the following are also signs of severe muscle damage: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electro-diagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezium and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. 4.56(d)(4) (2013). A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. There will be no rating assigned for muscle groups which act upon an ankylosed joint, except for an ankylosed knee, if muscle group XIII is disabled (rated at the next lower level than would otherwise be assigned), and an ankylosed shoulder, if muscle groups I and II are severely disabled (evaluation under diagnostic code 5200 will be elevated to the level for unfavorable ankylosis, if not already assigned, but the muscle groups will not be rated). The combined rating of muscle groups acting upon a single unankylosed joint must be lower than the rating for unfavorable ankylosis of that joint, except in the case of muscle groups I and II acting upon the shoulder. For compensable muscle group injuries that are in the same anatomical region but do not act on the same joint, the rating for the most severely injured muscle group will be increased by one level and used as the combined rating for the affected muscle groups. For muscle group injuries in different anatomical regions that do not act upon ankylosed joints, each muscle group injury shall be separately rated and the ratings combined under 38 C.F.R. § 4.25. 38 C.F.R. 4.55 (2013). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2013). That provisions does not require a separate rating for pain, but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. Spurgeon v. Brown, 10 Vet. App. 194 (1997). The Veteran's service medical records show that he sustained multiple fragment wounds to the abdomen and all extremities from a mortar explosion on March 14, 1969. The wounds were debrided, an exploratory laparotomy was performed with closure of multiple fragment wounds of the small bowel, and a right hemicolectomy was performed with a primary ileotransverse colostomy. Postoperatively, he had a fever that was felt to be due to gross fecal contamination of the peritoneal cavity. He was treated with antibiotics and his temperature returned to normal. He was prepared for medical evacuation but that was cancelled due to persistent fevers. Examination did not reveal any cause for the fevers and with time they subsided. He was eventually medically evacuated and admitted to Naval Hospital Memphis on April 19, 1969, with diagnoses of multiple shrapnel wounds to the abdomen and all extremities; perforation of the right colon; perforation of the terminal ileum; multiple small bowel perforations; status postoperative exploratory laparotomy with a right hemicolectomy and ileotransverse colostomy, and repair of terminal ileum and multiple small bowel perforations; status postoperative pericardiocentesis; right retroperitoneal abscess; complete small bowel obstruction secondary to adhesions; and status postoperative decompressive ileotomy. Other than a healed midline scar of the abdomen, examination at that time was within normal limits. He was sent on convalescent leave. Upon his return, he complained of bilateral flank pain and tenderness in the right lower quadrant, with a bout of constipation from May 11 to 15, 1969. There was some drainage from the abdominal wound and gauze packing was removed. He then complained of low back pain of increasing severity. He was diagnosed with a possible retroperitoneal abscess of the lower pole of the right kidney involving the perivertebral muscles. He underwent excision of the abscess. He did well postoperatively with complete cessation of the back pain and fever. On July 15, 1969, while still at the naval hospital, he was examined by a medical board and recommended for transfer to a VA hospital. He was discharged from service in September 1969. In his October 2005 claim for an increased rating, the Veteran indicated that his service-connected disabilities had worsened and were hindering his employment. He also indicated having stomach conditions due to the in-service wound. Initially, the Board notes that service connection is also in effect for residuals of a shell fragment wound with right hemicolectomy and anemia, and residuals of a retroperitoneal abscess of the left lumbar disc, both associated with the in-service shell fragment wound of the abdomen. Further, service connection for hypertrophic gastritis and hiatal hernia has been granted. Thus, the Board will focus on any other residuals, to include disability of muscle group XIX and any associated scars. During a March 2006 VA examination, the Veteran complained of gastrointestinal symptoms, including nausea, constipation, indigestion, heartburn, dysphagia, and abdominal pain. Examination of the abdomen showed a 9-inch linear scar and a 4-inch oblique scar, both of which were hyperpigmented and tender to pressure, with keloid formation. There was no muscle weakness or atrophy. The diagnosis was of abdominal pain status post fragment wound injury to the abdomen. The examiner indicated that the disability had significant effects on occupation, causing problems with lifting and carrying, and pain. In his January 2007 notice of disagreement, the Veteran indicated that he had pain, flare-ups, fatigue, and fatigue-pain. A January 2007 statement from a co-worker shows that the Veteran's physical stamina and strength had noticeably declined. During a February 2008 VA examination, the Veteran complained of pain, increased fatigability, and weakness. He reported weekly flare-ups of moderate severity lasting for hours that are precipitated by lifting, carrying, walking, or getting up and down. The examiner indicated that the injury was due to multiple low-velocity missiles but not a through-and-through wound, initially infected before healing, and treated in the field with six months of hospitalization. Examination showed an injury to the right abdominal wall involving muscle group XIX, muscle strength of 4/5, tissue loss with depression on the scars of about 0.5 to 1.0 inch, and intermuscular scarring evidence from the depth of the scars and weakness of the muscles on rising. The examiner indicated that muscle function was normal in terms of comfort, endurance, and strength sufficient to perform activities of daily living. There was a 10-inch scar and a 6-inch scar, both of which were painful or tender to touch and adherent to underlying tissue. The examiner indicated that there was no residual nerve, tendon, or bone damage, or muscle herniation. The examiner indicated that there was loss of deep fascia or muscle substance, but no limitation of motion of any joint. The examiner indicated that the disability had significant effects on occupation, causing decreased mobility, problems with lifting and carrying, and pain. During a November 2010 VA examination, the Veteran complained of worsening abdominal symptoms since the 2008 examination with pain mostly on the right side. He complained of pain, increased fatigability, and weakness. He reported weekly flare-ups of moderate severity lasting for hours that were precipitated by lifting, carrying, walking, or getting up and down. Examination showed an injury to the right abdominal wall involving muscle group XIX, muscle strength of 4/5, tissue loss with depression of the scars of about 0.5 to 1.0 inch, and intermuscular scarring evident from the depth of the scars. The examiner indicated that muscle function was normal in terms of comfort, endurance, and strength sufficient to perform activities of daily living. There was a 10 by 0.25 inch scar and a 6 by 0.25 inch scar, both of which were painful or tender to touch and adherent to underlying tissue. The examiner indicated that there was no residual nerve, tendon, or bone damage, or muscle herniation. The examiner stated that there was loss of deep fascia, but no limitation of motion of any joint or muscle atrophy. The diagnosis was of a shell fragment wound to the abdomen involving muscle group XIX with scars and scar tissue causing abdominal pain. The examiner indicated that the disability had significant effects on occupation, causing abdominal pain after eating that required reflux medication, and that the Veteran had to change job positions due to pain on lifting heavy packages. A January 2012 VA examination report shows a 9 by 0.25 inch scar that was tender to pressure and depressed but not unstable, and a 6 by 0.25 inch oblique scar that was not tender or unstable. Both scars were deep. The examiner indicated that the Veteran had abdominal pain after eating and had to take reflux medication, and that the Veteran had to change job positions due to pain on lifting heavy packages. VA medical records show that the Veteran had multiple healed surgical scars on the abdomen. Private medical records show treatment for digestive disorders. The Board finds that the Veteran's residuals of a shell fragment wound of the abdomen have been manifested by moderately severe disability of muscle group XIX to warrant a higher 30 percent rating. The evidence indicates moderately severe muscle disability. During the March 2006 examination, the Veteran complained of abdominal pain. Examination found no muscle weakness or atrophy. During the February 2008 and November 2010 examinations, the Veteran complained of pain, increased fatigability, and weakness and described his flare-ups as of moderate severity. Examinations showed slightly decreased muscle strength of 4/5, intermuscular scarring, and loss of deep fascia, but the examiner stated that muscle function was normal in terms of comfort, endurance, and strength sufficient to perform activities of daily living. The 2010 examiner specified that the Veteran has a shell fragment wound to the abdomen involving muscle group XIX with scars and scar tissue causing abdominal pain. With respect to the type of injury, the Veteran's injury is from a deep open penetrating wound, with debridement, prolonged infection, and intermuscular scarring. There is a history of hospitalization for a prolonged period with a record of consistent complaints of cardinal signs and symptoms of muscle disability. There is evidence of an inability to meet work requirements. Objectively, there is a loss of deep fascia and tests of strength and endurance demonstrate positive evidence of impairment. The above is consistent with moderately severe muscle disability. Thus, a higher 30 percent rating under Diagnostic Code 5319 is warranted. However, a higher 50 percent rating is not warranted as the Veteran's disability does not more nearly approximate severe muscle disability. Initially, the Board stresses that muscle strength was only slightly reduced at 4/5. Moreover, the examiner who conducted the February 2008 and November 2010 examinations indicated that muscle function was normal in terms of comfort, endurance, and strength sufficient to perform activities of daily living. With respect to the type of injury, although the Veteran's injury is from deep penetrating wounds due to multiple low-velocity missiles, there is no evidence of intermuscular binding. With respect to the cardinal signs and symptoms of muscle disability, there is no evidence of impairment of coordination or uncertainty of movement. Moreover, the Veteran described his flare-ups as of moderate severity. Thus, the cardinal signs and symptoms do not appear to be worse than those shown for moderately severe muscle injuries. Lastly, although objective findings include depressed and adherent scars and palpable loss of deep fascia, tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side do not indicate severe impairment of function. Again, muscle strength was only slightly reduced at 4/5. There are also no signs of severe muscle damage such as x-ray evidence of minute multiple scattered foreign bodies, adhesion of scars to bones, diminished muscle excitability, atrophy of any muscle, adaptive contraction of an opposing group of muscles, or induration of an entire muscle. Thus, the evidence does not show that the Veteran's residuals of a shell fragment wound of the abdomen more nearly approximate severe muscle disability. Lastly, although the shell fragment wound of the abdomen has resulted in two surgical scars, they are not compensable under the rating criteria. The rating criteria pertaining to scars were revised effective October 23, 2008. However, those changes only apply to claims filed on or after that date or when the veteran has specifically requested consideration under the new criteria, neither of which applies in this case. Thus, the Board will only consider the rating criteria in effect prior to October 23, 2008. Under Diagnostic Code 7801, scars other than on the head, face, or neck that are deep or cause limited motion and involve an area or areas exceeding 6 square inches (39 square centimeters) warrant a 10 percent rating. 38 C.F.R. § 4.118 (2008). However, the examinations of record does not show that the scars involve the requisite area. The scars involve at most 2.5 square inches (10 by 0.25 inches) and 1.5 square inches (6 by 0.25 inches), for a total of 4 square inches. The Board has considered whether any other applicable rating criteria may enable a higher rating. However, as Diagnostic Code 5319 is specific to the muscle injury the Veteran has, there are no other relevant diagnostic codes for consideration. While the Veteran does have tender of painful scars, those scars are deep, not superficial. Therefore, they cannot be rated for painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Instead, they are rated as other scars based on limitation of motion or function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Therefore, the muscle injury rating applies and compensates for the deep scarring involved. To assign any additional rating would be contrary to the rating schedule and would be impermissible pyramiding. 38 C.F.R. § 4.14 (2013). In conclusion, a higher 30 percent rating is warranted for the Veteran's residuals of a shell fragment wound of the abdomen involving muscle group XIX. However, as the preponderance of the evidence is against any higher rating that 30 percent, the claim for an even higher rating must be denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Additional Considerations The Board must also determine whether the schedular rating is inadequate, thus requiring a referral of the claim to the Under Secretary for Benefits or Director of Compensation and Pension Service for consideration of an extra-schedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability. 38 C.F.R. § 3.321(b)(1) (2013). An extra-schedular rating is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the service-connected disability. Thun v. Peake, 22 Vet. App. 111 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111 (2008). When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular rating is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2013); Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Board finds that the schedular rating is adequate. Ratings in excess of that assigned are provided for certain manifestations of the service-connected residuals of a shell fragment wound of the abdomen, but the medical evidence shows that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disability. As the rating schedule is adequate to rate the disability, referral for extra-schedular consideration is not in order. Although the Veteran has made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable, due to his service-connected disability. Although the record shows that his job duties were changed, the Veteran remains employed. Thus, the matter of entitlement to a total disability rating based on individual unemployability due to service-connected disability has not been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER A 30 percent rating for the residuals of a shell fragment wound of the abdomen involving muscle group XIX is granted, subject to the provisions governing the award of monetary benefits. REMAND Pursuant to the Joint Motion for Partial Remand, the Board finds that consideration of staged ratings is appropriate for the Veteran's psychiatric disability. However, the Board finds that further development is needed prior to that consideration. In a January 2013 letter, a co-worker of the Veteran indicated that his psychiatric disability had worsened in the past year. The coworker stated that the Veteran had become very forgetful and indicated that she had to check his work to ensure accurate completion and follow-through. The Board observes that forgetting to complete tasks is a criterion for consideration in the rating criteria for mental disorders. 38 C.F.R. § 4.130 (2013). The Veteran was last afforded a VA examination for his psychiatric disability in November 2010. At that time, the Veteran's memory was found to be normal and the examiner indicated that the Veteran's psychiatric disability was not severe enough to interfere with occupational functioning. However, the evidence now indicates that he is forgetting to complete tasks, which indicates that his disability may be interfering with occupational functioning and may indicate impairment in memory. The December 2007 VA examination found mild impairment in recent and immediate memory. As the November 2010 examination findings are now almost three years old, and the record indicates that the Veteran's psychiatric disability may have worsened since that time, he should be provided a new examination to determine the current severity of his disability. Prior to the examination, any outstanding VA medical records should be obtained. The record contains treatment notes from the VA Tennessee Valley Healthcare System through February 2010. Thus, any treatment notes since that time should be obtained. Accordingly, the case is REMANDED for the following actions: 1. Obtain any records of treatment from the VA Tennessee Valley Healthcare System since February 2010. 2. Then, schedule the Veteran for a VA psychiatric examination to determine the current severity of his PTSD. The examiner should provide a full multi-axial diagnosis pursuant to DSM-IV, to include a GAF score related to the Veteran's PTSD. The examiner should also indicate the degree of social and occupational impairment due to the Veteran's PTSD. The examiner should review the claims folder and should note that review in the examination report. A rationale for all opinions should be provided. 3. Then, readjudicate the claim. If any benefit sought on appeal remains denied, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs