Citation Nr: 1338850 Decision Date: 11/26/13 Archive Date: 12/06/13 DOCKET NO. 06-24 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to a disability rating higher than 10 percent for gunshot wound residuals of the right thigh prior to July 5, 2012, and higher than 30 percent thereafter. 2. Entitlement to a disability rating higher than 10 percent for gunshot wound residuals of the left thigh prior to July 5, 2012, and higher than 30 percent thereafter. 3. Entitlement to an initial disability rating higher than 30 percent for posttraumatic stress disorder (PTSD) prior to May 21, 2006, higher than 50 percent prior to April 16, 2012, and higher than 70 percent thereafter. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and D.H. ATTORNEY FOR THE BOARD Cheryl E. Handy, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from September 1964 to March 1967, including service in the Republic of Vietnam for which he received the Navy Commendation Medal. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in November 2005 of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, which continued 10 percent disability ratings for right and left leg gunshot wound residuals and assigned an initial 30 percent disability rating for PTSD. A subsequent rating decision in December 2010 granted a 50 percent disability rating for PTSD effective May 21, 2006. Another rating decision in April 2013 granted a 70 percent disability rating for PTSD effective April 16, 2012, and 30 percent disability ratings for each leg effective July 5, 2012. All of the assigned ratings are currently on appeal before the Board. In July 2010, the Veteran appeared at a hearing at the RO before a Decision Review Officer. A transcript of that hearing is in the claims file. In July 2013, the Veteran appeared at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is also in the claims file. The issues of entitlement to service connection for right and left hip and right and left knee disabilities secondary to the left ankle, right thigh, and left thigh disabilities have been raised by the record, but have not been adjudicated by the RO. Therefore, the Board does not have jurisdiction over them, and they are referred to the RO for appropriate action. The issue of entitlement to TDIU is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appeals period, the Veteran's gunshot wound residuals of the right thigh have been productive of a moderately severe injury to Muscle Group XV, characterized by a through and through injury with loss of deep muscle fascia, loss of stamina, weakness, fatigue, and pain. 2. Throughout the appeals period, the Veteran's gunshot wound residuals of the left thigh have been productive of moderately severe injuries to Muscle Groups XIV and XV, characterized by a through-and-through injury with loss of deep muscle fascia, loss of stamina, weakness, fatigue, pain, and retained foreign bodies. 3. Throughout the appeals period, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas including work, school, family relations, judgment, thinking, or mood and a GAF score of 45. CONCLUSIONS OF LAW 1. The criteria for a 30 percent disability rating for gunshot wound residuals of the right thigh in Muscle Group XV, and no higher, effective June 2, 2005, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5315 (2013). 2. The criteria for a 40 percent disability rating for gunshot wound residuals of the left thigh in Muscle Groups XIV and XV, and no higher, effective June 2, 2005, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5302 (2013). 3. The criteria for a 70 percent disability rating for PTSD, and no higher, effective June 2, 2005, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Duty to Notify Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased rating claim for PTSD arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. In a claim for increase, the VCAA 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, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). With respect to the claims for increased disability ratings for the gunshot wound residuals of the legs, the Veteran was sent letters in June 2005, March 2006, and June 2009 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The June 2009 letter also explained what type of information and evidence was needed to establish a disability rating and effective date. The Board acknowledges that, in the present case, complete notice was not issued prior to the adverse determination on appeal. However, fully compliant notice was later issued in the June 2009 communication, and the claim was thereafter readjudicated in December 2010. Accordingly, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was provided VA examinations in July 2005, February 2010, and July 2012 to assess the nature and severity of his gunshot wound residuals. An addendum opinion reconciling discrepancies in the examinations was also provided in January 2013. With respect to his claim for PTSD, the Veteran was provided VA examination in September 2005, February 2010, and April 2012. The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the disability on appeal to provide probative medical evidence adequate for rating purposes. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board has reviewed the electronic evidence contained in the Veteran's Virtual VA folder as well as the paper file. These files together comprise the claims file. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a July 2013 hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused 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 Veteran's claim. The United States Court of Appeals for Veterans Claims (Court) has held that that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At his hearing the undersigned identified the issue, sought information as to treatment to determine whether all relevant records had been obtained, and sought information as to any changes in the disability since the last examination. Ultimately the claim was remanded for a new examination. The Board thereby met the duties imposed by 38 C.F.R. § 3.103(c)(2) as interpreted in Bryant. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Principles of Assigning Disability Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. 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 conditions in civil occupations. 38 U.S.C.A. § 1155. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Here, the RO assigned staged ratings for the Veteran's right and left leg disabilities and for his PTSD. On considered review of the entire record, the Board finds that staged ratings are not appropriate and that the higher disability ratings should prevail for the entire appeals period. Evaluating Gun Shot Wound Residuals Muscle injuries, including from gun shots, are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions. 38 C.F.R. § 4.55(b). The specific bodily functions of each group are listed at 38 C.F.R. § 4.73. Guidance in rating muscle injuries is set out at 38 C.F.R. § 4.56, which discusses factors to be considered in the evaluation of disabilities residual to healed wounds involving muscle groups due to gunshot wounds or other trauma. Muscle group injuries or trauma are evaluated on the basis of the following factors: the velocity, trajectory and size of the missile which inflicted the wounds; extent of the initial injury and duration of hospitalization; the therapeutic measures required to treat the disability; and current objective clinical findings. 38 C.F.R. § 4.56. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). 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, and disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. 38 C.F.R. § 4.56(c), (d). Under 38 C.F.R. § 4.56(d), a slight muscle disability is one where the injury was a simple wound of muscle without debridement or infection. The service department record would show a superficial wound with brief treatment and return to duty. There would be healing with good functional results. There are no cardinal signs or symptoms of muscle disability as denied in 38 C.F.R. § 4.56(c). Objectively, there would be a minimal scar, with no evidence of fascial defect, atrophy, or impaired tonus. There would be no impairment of function, or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). A moderate muscle disability is one where the injury was either through and through, or a deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the effect of high velocity missile, residuals of debridement, or prolonged infection. The service department record (or other evidence) would show inservice treatment for the wound. There would be a consistent complaint of one or more of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), particularly a lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, the entrance (and if present, exit) scars would be 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 would be present. 38 C.F.R. § 4.56(d)(2). A moderately severe muscle disability is one where the injury was either through and through, or a deep penetrating wound by a small high velocity missile or large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), and, if present, an inability to keep up with work requirements. Objectively, the entrance (and if present, exit) scars would indicate the track of missile through one or more muscle groups. There would be 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 demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). A severe muscle disability is one where the injury was either through and through, or a deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or one with a shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.456(c), which would be worse than that shown for moderately severe injuries, and, if present, an inability to keep up with work requirements. Objectively, there would be ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation would show loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles would swell or harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. If they happen to be present, the following would also be signs of severe muscle injury: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intramuscular 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 electrodiagnostic tests; (D) Visible or measurable atrophy; (E) Adaptive contraction of an opposing group of muscles; (F) Atrophy of muscle groups not in track of the missile, particularly of the trapezius 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). The record shows that the Veteran sustained gunshot wounds to both thighs in service, with one wound in his right thigh and two in his left. Entrance and exit wounds are present for all injuries and demonstrate that those wounds were through and through and affected Muscle Group XV in both thighs, as well as Muscle Group XIV in the left thigh. Diagnostic Code 5314 provides that injuries to Muscle Group XIV will be rated as 10 percent for moderate injuries, 30 percent for moderately severe injuries, and 40 percent for severe injuries. Diagnostic Code 5315 provides that injuries to Muscle Group XV will be rated as 10 for moderate injuries, 20 percent for moderately severe injuries, and 30 percent for severe injuries. 38 C.F.R. § 4.71a. The Veteran was assigned 10 percent disability ratings for each thigh after service separation in 1968. His claim for an increased disability rating for each thigh was received in June 2005. Inasmuch as the record clearly shows that the Veteran sustained a through and through muscle injury of Muscle Group XV in each thigh, each should be rated as at least moderate or 10 percent disabling. The Board must consider whether a still higher disability rating is warranted for either injury. VA examinations were conducted of the Veteran's gunshot wound residuals in July 2005, February 2010, and July 2012. All examinations describe injuries to Muscle Group XV in both thighs, as well to Muscle Group XIV in the left thigh. A January 2013 addendum opinion explained that the specific muscles affected were the right gracilis muscle, the left gracilis muscle, and the left rectus muscle. The gracilis muscle is included in Muscle Group XV and the rectus muscle is in Muscle Group XIV. Both of these muscle groups are involved in hip and knee flexion. Specific symptoms noted on examination with respect to both thighs include the presence of exit and entrance wounds, some loss of deep muscle fascia, lowered threshold of fatigue, and soft flabby muscles in the wound area. He had normal muscle strength bilaterally and minor muscle atrophy, but did experience ongoing pain and weakness in his legs. The Veteran reported he was unable to exercise, engage in prolonged walking or squatting, and his gait was slower because of his injuries. Three was no decreased range of motion with repetition and no impairment of muscle function on testing. His scars were all nontender and well-healed, with no instability. He had two scars, each 6 cm by 1 cm on the left leg and one scar measuring 6 cm by 1 cm on the right leg. Based on this evidence, the Board finds that the Veteran's right leg disability is more appropriately considered moderately severe and entitled to a 30 percent disability rating. The injuries caused by through and through wound of small high velocity missile with hospitalization treatment and loss of muscle facia and substance, as well as consistent complaints of weakness, lowered threshold of fatigue and fatigue-pain are all consistent with the rating criteria for a moderately severe disability rating for the right leg. While he does have evidence of soft flabby muscles in the wound area, none of the other criteria are met for a severe disability rating. The Veteran's left leg disability is more complicated because it is the result of two separate, if simultaneous, gunshot wounds which impacted two separate muscle groups, XIV and XV. Where the Veteran has two separate muscle group injuries in the same anatomical region, and each muscle group acts on more than one joint, the provisions of 38 C.F.R. § 4.55 (e) would apply. The symptoms associated with the left leg gunshot wound residuals are the same as those discussed above with respect to the right leg gunshot wound residuals, but also include the presence of multiple small retained foreign bodies in the left thigh. Like the evidence of soft flabby muscles, the presence of retained foreign bodies is one consideration listed for severe muscle group injuries; however, none of the other criteria for a severe muscle disability are met. Based on the considerations of 38 C.F.R. § 4.55(e) and the specific symptoms related to the two injuries of the Veteran's left leg, it appears that the Veteran's injury to Muscle Group XIV is more severe than that to Muscle Group XV based on the presence of the retained foreign bodies. As such, the evaluation for the left leg, considering the combined effects of both Muscle Group injuries, should be increased from moderately severe to severe, or a single 40 percent disability rating. The staged rating as assigned by the RO was based on the date of the examination at which the specific symptoms complained of by the Veteran were officially documented. A review of the record, however, shows that the Veteran's complaints of symptoms have been consistent throughout the appeals period and at the VA examinations conducted since the filing of the increased rating claim. As the nature of the Veteran's disability has not changed, a consistent disability rating for each injury, that is, 30 percent for the right leg and 40 percent for the left leg, is granted effective June 2, 2006. In addition to the question of Muscle Group injuries, the Board has also considered the other residuals of the Veteran's gunshot wounds, the scars on both legs. The rating criteria pertaining to scars were revised in October 2008. As the Veteran's gunshot wound scars were not previously rated, any potential for compensable rating would be based on the new criteria. The most pertinent criteria would be those of Diagnostic Code 7801 which provides that scars not on the head or face which are deep (associated with underlying soft tissue damage) and nonlinear and at least 6 square inches in area are rated as 10 percent disabling. Here, the Veteran's scars, even combined, do not cover an area of 6 square inches, and a compensable disability rating would not be warranted. Other scar rating criteria are not applicable. On one examination the Veteran described his scars as painful but the examiner specifically noted that they were not tender to palpation. The remaining examinations noted nontender scars. As such, Diagnostic Code 7804 governing unstable or painful scars is not applicable. Finally, the Board acknowledges the Veteran's statements at the July 2013 hearing that his leg disabilities have worsened since the most recent VA examination, specifically resulting in increased pain and difficulty getting around. The decision herein grants the maximum possible rating for the Veteran's left leg for either affected Muscle Group, a further delay in adjudicating the Veteran's claim to afford him another examination would be of no benefit on that issue. On the issue of the Veteran's right leg disability, the Board notes that the nature of a disability rating for gunshot wound residuals is governed in part by the type of injury, the history and complaint, and by the objective findings like scars and loss of muscle substance. The only potential change in symptoms which could conceivably result in a higher disability rating is that related to the cardinal signs and symptoms of muscle disability set out in 38 C.F.R. § 4.56(c). The Veteran's testimony indicated possible impairment of coordination as a new symptom; however, the addition of one new symptom would not be sufficient to render a material change in the severity of the disability under 38 C.F.R. § 4.56. As such, a remand for further examination of the disability would merely delay adjudication of the Veteran's claim without resulting in a substantive benefit to him. For this reason, the Board has elected to adjudicate the claim rather than issue a needless remand. In short, the Veteran is entitled to a 40 percent disability rating for the left leg disability for the entire appeals period and to a 30 percent disability rating for the right leg for the entire appeals period. As the criteria for compensable disability ratings for scars have not been met, the Board will not assign separate ratings for the Veteran's six scars resulting from his gunshot wounds. Rating PTSD The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: 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 normal conversation), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) warrants a 30 percent evaluation. A rating of 50 percent is assigned when it results in 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; and difficulty in establishing and maintaining effective work and social relationships. 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, is assigned a 70 percent rating. 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 of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, merits a 100 percent rating. 38 C.F.R. § 4.130. The evidence considered in determining the level of impairment from posttraumatic stress disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the diagnosis of posttraumatic stress as used by the American Psychiatric Association, such as the Global Assessment of Functioning (GAF) score. The GAF score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score of 51 to 60 indicates that the examinee has 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 co-workers). A GAF score of 41 to 50 indicates that the examinee has serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). See Richard v. Brown, 9 Vet. App. 266, 267 (1996). The RO, in granting the Veteran's claim for PTSD, assigned an initial disability rating of 30 percent, with subsequent staged ratings of 50 and 70 percent over the course of the appeals period. These ratings were based on the results of the VA examinations and the effective dates assigned were those of the examinations as well. In reviewing the record, the Board notes that the Veteran's treating mental health providers have described a largely stable disability picture relative to the Veteran's PTSD. A communication from the Veteran's VA social worker and treating mental health provider in June 2006 took issue with the initial 30 percent disability rating assigned, feeling that it did not accurately reflect the severity of his symptoms and his poor overall functioning. The provider felt that the assignment of a GAF score of 60 by the VA examiner was "possibly due to [the] Vet[eran]'s very quiet and minimizing presentation to cover his embarrassment." The social worker noted severe symptoms of PTSD including intrusive thoughts, re-experiencing, detachment, restricted affect, derealization, insomnia, difficulty with concentration, inability to recall important people and events associated with the trauma, and suicidal ideation, all of which had increased dramatically over the past two years because of inability to work and social isolation. "I cannot conceive of this Veteran being able to function in a work environment." Throughout the appeals period similar sentiments have been repeated by the Veteran's mental health providers and all have repeatedly assigned him GAF scores of 45. Based on the consistent presentation of symptoms over the course of the appeals period and the consistent opinion of the Veteran's treating mental health providers, the Board finds that a 70 percent disability rating is appropriate for the entire appeals period. The most recent VA examination assigned a GAF score of 52 and equated the Veteran's occupational and social functioning to one with significant impairments in all areas, the language of the 70 percent rating criteria. This coincides with the description of the Veteran's functioning throughout the entire appeals period and supports a single disability rating for the whole time span. A still higher, that is, 100 percent disability rating, is not warranted here. Total occupational and social impairment has not been shown, as evidenced by the Veteran's ongoing, if strained, relationships with his children, and his few friendships. The Veteran has also not exhibited the symptoms associated with total mental disability, such 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 of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As such, while the Veteran may not be deemed capable of functioning in a work environment by his mental health providers, his disability picture is not consistent with that of a 100 percent disability rating for PTSD. Extraschedular Rating Although the Board is precluded by regulation from assigning extraschedular ratings under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for a service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and provided for higher ratings for more severe symptoms. As the disability pictures are contemplated by the Rating Schedule, the assigned schedular ratings are, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to a 30 percent disability rating for gunshot wound residuals of the right thigh in Muscle Group XV, and no higher, effective June 2, 2005, is granted, subject to the laws and provisions governing the award of monetary benefits. Entitlement to a 40 percent disability rating for gunshot wound residuals of the left thigh in Muscle Groups XIV and XV, and no higher, effective June 2, 2005, is granted, subject to the laws and provisions governing the award of monetary benefits. Entitlement to a 70 percent disability rating for PTSD, and no higher, effective June 2, 2005, is granted, subject to the laws and provisions governing the award of monetary benefits. REMAND The Veteran also seeks a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In addition to raising a separate claim for this benefit, the Veteran is entitled to consideration of TDIU as part of his claims for increased disability ratings. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Eligibility for TDIU is based on a showing that the Veteran's service-connected disabilities are of such severity as to render him unable to obtain and maintain reasonably gainful employment. In this instance, there is evidence that his disabilities may rise to the level of unemployability; however, there is confusion in the record over when he was rendered unemployable. Various statements indicate that he was unable to work beginning in 2003, or in 2005, or in 2008. Specific evidence as to the date of unemployability is critical in determining entitlement to TDIU benefits. Such evidence, to include possible Social Security or Internal Revenue records, should be obtained on remand. Further, the intertwined issues of entitlement to service connection for additional disabilities should also be addressed and a medical opinion obtained on the cumulative effects of all service-connected disabilities. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to submit evidence, to include copies of either Social Security or Internal Revenue Service documents, showing the exact date at which his employment, to include self-employment, ended. 2. Adjudicate the Veteran's additional claims of service connection for right and left knee and right and left hip disabilities discussed in the Introduction to this Decision and Remand. 3. Perform any other indicated development suggested by the results of the development ordered above, to include arranging for an examination, if necessary, to address whether the Veteran's current service-connected disabilities, singly or in any combination, to include any additional disabilities found pursuant to Remand Instruction 2 above, have rendered him unable to obtain and maintain reasonably gainful employment that his education and occupational experience would otherwise permit him to undertake. If the examiner determines that the Veteran is unable to obtain and maintain reasonably gainful employment, he or she should furnish an opinion as to the date at which the Veteran attained this status. The examiner should provide the reasons for any opinions. A copy of the claims file should be provided to the examiner for review. 4. On completion of the foregoing, the claim should be adjudicated. If the decision remains adverse to the Veteran, then provide him and his representative a supplemental statement of the case and 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 remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs