Citation Nr: 20071069 Decision Date: 11/04/20 Archive Date: 11/04/20 DOCKET NO. 13-20 056 DATE: November 4, 2020 ORDER Entitlement to an increased rating of 60 percent for Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm is granted. FINDING OF FACT Throughout the period on appeal, the Veteran’s Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm was manifested by severe symptoms consisting of daily fatigue and malaise with diarrhea, intermittent weight loss, definite interference with nutrition and absorption, abdominal distension, anemia, and intermittent nausea. CONCLUSION OF LAW The criteria for an increased rating of 60 percent, but no higher, for Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.114, Diagnostic Code 7323-7345. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1969 to September 1971. The Board iIn August 2017, the Board granted a separate noncompensable rating for hepatitis C and denied an increased rating for Crohn’s disease with right partial colectomy and terminal resection. The Veteran appealed the decision to the Court of Appeals for Veterans Claims (Court). In November 2018 the Court, pursuant to a Joint Motion for Partial Remand filed on behalf of the parties, vacated the Board’s August 2017 decision that a rating in excess of 40% was not warranted for Crohn’s disease with right partial colectomy and terminal resection. Specifically, the parties agreed that the Board had failed to provide an adequate statement of reasons and bases to support its decision when it (1) did not state what weight it gave to the September 18, 2015 Disability Benefits Questionnaire indicating that a 100 percent rating was warranted, (2) did not explain why the Veteran was not entitled to an elevation to the next higher schedular rating under 38 C.F.R. § 4.114, and (3) did not explain why a separate rating was not assigned under Diagnostic Code 7332 for “occasional involuntary bowel movements necessitating wearing a pad.” See November 2018 Joint Motion for Partial Remand. The Board remanded the claim in August 2019 to allow the Agency of Original Jurisdiction to consider additional evidence received and issue a Supplementary Statement of the Case (SSOC) and to provide the Veteran a new VA examination. New examinations were obtained in December 2019, and the AOJ issued an SSOC in July 2020. The claim now returns to the Board for further adjudication. 1. Entitlement to an increased rating for Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm. The Veteran seeks a higher rating for his service-connected Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm. After reviewing the evidence, the Board concludes a rating of 60 percent, but no higher, for Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm (“Crohn’s disease”), is warranted for the entire period on appeal. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1. VA must consider whether the Veteran is entitled to “staged” ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran currently has a 40 percent disability rating for his service-connected Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm. The rating is assigned under hyphenated Diagnostic Code 7323-7345. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 7323 addresses ulcerative colitis. Moderate ulcerative colitis, with infrequent exacerbations, is rated 10 percent disabling. Moderately severe ulcerative colitis, with frequent exacerbations, is rated 30 percent disabling. Severe ulcerative colitis, with numerous attacks a year and malnutrition, the health only fair during remissions, is rated 60 percent disabling. Pronounced ulcerative colitis, resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess, is rated 100 percent disabling. 38 C.F.R. § 4.114, Diagnostic Code 7323. Diagnostic Code 7345 addresses chronic liver disease without cirrhosis. A noncompensable rating is warranted for non-symptomatic chronic liver disease. A 10 percent rating is warranted for liver disease manifested by intermittent fatigue, malaise, and anorexia, or if there are incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period. A 20 percent rating is warranted for liver disease manifested by daily fatigue, malaise and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or incapacitating episodes (with symptoms as described above) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A 40 percent rating is warranted with symptoms of daily fatigue, malaise and anorexia, with minor weight loss and hepatomegaly, or incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. Chronic liver disease with daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12- month period, but not occurring constantly, is rated 60 percent disabling. Chronic liver disease with near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain), is rated 100 percent disabling. 38 C.F.R. § 4.114, Diagnostic Code 7345. Note (1) to Diagnostic Code 7345 provides that sequelae, such as cirrhosis or malignancy of the liver, is to be rated under an appropriate diagnostic code, but not to use the same signs and symptoms as the basis for rating under Diagnostic Code 7354 and under a diagnostic code for sequelae. Note (2) provides that, for purposes of rating conditions under Diagnostic Code 7345, “incapacitating episode” means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. 38 C.F.R. § 4.114, Diagnostic Code 7345. Ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Factual Background The Veteran filed his claim for an increased rating for Crohn’s disease in December 2009. He was afforded a VA examination for Crohn’s disease in February 2010. The Veteran denied nausea and vomiting but did experience diarrhea 6 to 12 times per day with mucus but no visible blood. He experienced general abdominal discomfort associated with the diarrhea, and his appetite was good. He had lost 6 pounds over the previous year. In a March 2010 Social Security Administration (SSA) filing, the Veteran reported that due to fatigue and lack of energy he required a daily 2-hour nap. He was able to shop, wash dishes, and do light laundry, but no lifting or yard work. The extent of his ability to perform household chores was dependent on his energy level. He also reported that his social activities had decreased significantly due to lack of energy and other symptoms. In a November 2010 SSA filing, the Veteran described how his activities of daily living, such as bathing and dressing, were affected by fatigue. The fatigue also adversely affected his ability to exercise In May 2010, the Veteran was admitted to the hospital for weakness and fatigue. There had not been associated nausea or vomiting and his appetite had been good. The following day, he underwent an exploratory laparotomy, extensive lysis of adhesions, and ileocolectomy with primary anastomosis. The Veteran received a temporary100 percent disability rating for his period of hospitalization and convalescence from this surgery from May 19, 2010, to July 1, 2010, and this period is not in appellate status. In an August 2010 statement, the Veteran reported he was not feeling well and that due to his Crohn’s disease he had between 4 and 12 bowel movements per day. He also reported atrial fibrillation and that he continued to lose weight. In a December 2010 private appointment, the Veteran complained of fatigue and reported he needed to take a 2-hour nap every day. The treating doctor noted his Crohn’s disease had been exacerbated by a recent colonoscopy or new medication. The Veteran reported 5 to 6 loose bowel movements every day but denied nausea or vomiting. The Veteran was provided another VA examination for Crohn’s disease in March 2012. Continuous medication was not required to control Crohn’s disease. The examiner noted moderate symptoms, including several bowel movements per day that were watery, mucousy, and/or partially soft. The Veteran had abdominal cramps several times per day, mostly after meals, and gaseous abdominal distention about once per week with occasional nausea. There were occasional episodes of bowel disturbance with abdominal distress. The examiner noted no weight loss or malnutrition attributable to the Crohn’s disease. The Veteran reported that he had been unemployed since 2009 due to lack of energy and needing a nap in the middle of the day. He was afforded a VA intestinal conditions examination in April 2013. Continuous medication was required and consisted of cole calciferol and azithromycin as needed. Symptoms attributed to Crohn’s disease were alternating diarrhea and constipation. There were occasional episodes of bowel disturbance and abdominal distress. There was no weight loss or malnutrition attributable to the Crohn’s disease. The examiner noted the Crohn’s disease was “fairly stable” but the Veteran had to monitor his activity and eating habits, and that when considered in relationship to the Veteran’s other problems, the Crohn’s disease is more difficult to manage and made it difficult for the Veteran to work. He was also provided a VA intestinal surgery examination in April 2013. The examiner noted prior resection of the small intestine with ongoing intermittent diarrhea. There was no weight loss or an inability to gain weight due to the surgeries, and the surgeries also did not interfere with absorption and nutrition. There were occasional episodes of bowel disturbance with abdominal distress. The Crohn’s disease did not require an ileostomy or colostomy and did not result in a persistent intestinal fistula. An April 2013 private treatment record documented that the Veteran experienced 3 to 4 loose but formed bowel movements per day without nocturnal symptoms, abdominal pain, mucus, or blood. The Veteran's weight was stable, without nausea, vomiting, and abdominal pain. He reported that his energy was up and denied fatigue. In support of his claim, the Veteran submitted a June 2013 Hepatitis, Cirrhosis, and other Liver Conditions Disability Benefits Questionnaire (DBQ) completed by a private physician. The doctor noted diagnoses of hepatitis C and cirrhosis of the liver, and that the Veteran had advanced fibrosis/cirrhosis based on elevated blood levels testing. There was daily fatigue and malaise. The Veteran had incapacitating episodes due to the liver conditions with a total duration of 6 weeks or more during the past 12 months. The Veteran did not currently have any symptoms attributable to his cirrhosis. He was also afforded a VA examination for hepatitis and cirrhosis in June 2013. The Veteran reported 3 to 4 loose but formed stools per day, without any symptoms during the night. He reported very profound fatigue throughout the day that limited his activities. The document reported malaise and indicated that the Veteran had not had any incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) due to the liver conditions during the past 12 months. Symptoms attributable to the Veteran’s cirrhosis included daily weakness and malaise. The examiner noted that a combination of the Veteran’s medical problems resulted in him stopping work in December 2009, The Veteran submitted a September 2015 Intestinal Conditions DBQ completed by Dr. R.D., a private doctor. Dr. R.D. noted diagnoses of chronic diarrhea, Crohn’s disease, chronic recurrent pancreatitis, and chronic hepatitis C with cirrhosis. The Veteran had multiple small bowel resections and that the Veteran had short bowel syndrome with malabsorption secondary to the bowel resections. Associated symptoms included diarrhea, abdominal distension, anemia, nausea, and chronic worsening abdominal pain. There were frequent episodes of bowel disturbance with abdominal distress, as well as episodes of exacerbations and attacks of the intestinal condition that were manifested by worsening upper abdominal pain. There had been a total of 4 exacerbations and/or attacks in the previous 12 months. There was no weight loss attributable to the intestinal condition. Other complications included general debility, marked malnutrition, and cirrhosis secondary to the hepatitis C. There was a history of malignant neoplasm of the kidney. Ongoing complications of the kidney cancer were multiple attacks of pancreatitis and questionable recent Crohn’s exacerbation that needed to be evaluated. The Veteran was unable to work due to the problems involved in the Crohn’s disease, pancreatitis, and chronic pain. A September 2015 Intestinal Surgery DBQ noted resections of the small and large intestines for his Crohn’s disease, most recently in May 2010. Associated symptoms were diarrhea, anemia, nausea, and abdominal pain. There was weight loss due to diarrhea and malabsorption. The weight loss had not been sustained for 3 months or longer and he had been able to regain weight with appropriate therapy. The doctor determined the weight loss caused severe impairment of health and there was definite interference with absorption and nutrition. The Veteran was afforded a VA intestinal conditions examination in December 2019. The examiner diagnosed chronic diarrhea and Crohn’s disease. The Veteran would currently have diarrhea for days at a time, then will “go for a bit” with formed stools. He reported at least a week per month with diarrhea many times a day, and pain with the chronic diarrhea. Continuous medication was not required. Signs and symptoms attributable to intestinal conditions were diarrhea and abdominal distension due to bloating and gas. The examiner noted that multiple organs have been affected by the Veteran’s Crohn’s disease and complications after multiple surgeries, including kidney stones, kidney cancer, hepatitis C, type II diabetes, pancreas tumors and pancreatitis, atrial fibrillation, and cirrhosis of the liver. The examiner noted more or less constant abdominal distress. There were episodes of exacerbations and attacks of the intestinal condition consisting of daily intestinal issues with flares of diarrhea and pain for a week or more, with 7 or more attacks in the previous 12 months. There was no weight loss attributable to an intestinal condition. However, the examiner did find malnutrition attributable to the Crohn’s disease, noting the Veteran will lose 2 to 5 pounds with his monthly Crohn’s flares. He was also afforded an intestinal surgery VA examination in December 2019. The examiner noted severe symptoms attributable to resection of the intestine, including pain and chronic diarrhea several times a day and abdominal distension most days. There was no weight loss or inability to gain weight attributable to intestinal surgery, and the examiner determined interference with absorption and nutrition due to resection of the small intestine was not applicable. Analysis After considering the evidence of record, the Board finds that a rating of 60 percent for the Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm, is warranted under Diagnostic Code 7323 for the entire period on appeal. Diagnostic Code 7323 refers to ulcerative colitis. To warrant a 60 percent rating under Diagnostic Code 7323, the Veteran’s Crohn’s disease would need to more closely approximate severe symptoms with numerous attacks a year and malnutrition, with health only fair during remissions. The evidence supports such a finding for the entire period on appeal. The Veteran has consistently reported severe daily fatigue and malaise which ultimately caused him to quit working and has been consistent in describing occasional flareups and attacks of Crohn’s disease consisting of gastrointestinal pain, bloating, and multiple daily episodes of diarrhea. There is conflicting medical evidence regarding how severe the Veteran’s Crohn’s disease was during the early portion of the period on appeal. In February 2010 the Veteran had daily diarrhea with 6 to 12 loose stools per day and lower abdominal discomfort, and he had been out of work since December 2009 due to fatigue and malaise. The examiner noted that his activities were markedly reduced. Although moderate symptoms were noted on the March 2012 VA examination, the Veteran had quit working due to lack of energy, and he reported experiencing several bowel movements per day, abdominal cramps several times per day, gaseous abdominal distention, episodes of bowel disturbance and abdominal distress, and nausea. At the April 2013 VA examinations, he had alternating diarrhea and constipation with occasional episodes of bowel disturbance with abdominal distress, and continuous medication was required to manage the Veteran’s symptoms. An April 2013 private treatment record documented that the Veteran experienced 3 to 4 bowel movements per day. The June 2013 private DBQ daily fatigue and malaise with incapacitating episodes with a total duration of 6 weeks or more during the past 12 months. The June 2013 VA examination shows 3 to 4 loose stools per day with very profound fatigue throughout the day, but the examiner found that the Veteran had not had any incapacitating episodes during the past 12 months. The examiner also noted that a combination of the Veteran’s medical problems, including Crohn’s disease and his gastrointestinal surgeries, resulted in him stopping work in December 2009. However, the Veteran has had severe symptoms with multiple exacerbations consisting of pain and diarrhea throughout the period on appeal. Many of the same symptoms were reported on the private September 2015 DBQ examinations, including diarrhea, abdominal distension, chronic abdominal pain, and nausea. There were also frequent episodes of bowel disturbance and attacks, similar to his reports in the February 2010 and March 2012 VA examinations. The September 2015 intestinal surgery DBQ was the first examination report to identify malnutrition. At the December 2019 VA intestinal conditions examination, the Veteran had chronic recurring diarrhea and abdominal pain, with abdominal distension and constant abdominal distress with episodes of exacerbations and attacks consisting of daily intestinal issues with flares of diarrhea and pain for a week or more, with 7 or more attacks in the previous 12 months. The examiner also found malnutrition attributable to the Crohn’s disease, noting the Veteran will lose 2 to 5 pounds with his monthly Crohn’s flares. These symptoms and findings were severe, there were numerous attacks and flareups of Crohn’s per year, and the Veteran had malnutrition, fitting squarely within the 60 percent criteria under Diagnostic Code 7323. Taken together, the evidence reflects that the Veteran’s Crohn’s disease and associated symptoms have varied in severity and duration throughout the period on appeal, with periods of mild symptoms and much more severe symptoms. The Veteran has continuously reported multiple bowel movements per day with constant abdominal discomfort and pain, and that he will have numerous “attacks” per year consisting of at least one week per month of increased symptoms. Laboratory results have shown anemia, and a private September 2014 colonoscopy report shows bleeding at the site of the Veteran’s prior colon surgery. He has averaged multiple bowel movements per day, even outside of his monthly flareups, with severe fatigue and malaise throughout the period on appeal. In addition, he has been unable to work due to fatigue and malaise attributable in part to Crohn’s disease since 2009. There have been varying reports relating to malnutrition, with no malnutrition formally identified in private or VA examinations before 2015. However, VA treatment records show the Veteran was diagnosed with a Vitamin B12 deficiency in November 2003, which was presumed secondary to ileal resection due to Crohn’s disease. See, e.g., November 2003 VA Primary Care Notes. Vitamin B12 deficiency due to ileal resection was also noted in a January 2010 VA examination. furthermore, a June 2011 letter from the Veteran’s VA physician shows that the Veteran had received B12 injections in the past and that lab results suggested the Veteran had a B12 deficiency. More recent VA treatment records continued to show a vitamin D12 deficiency as an active problem. This evidence indicates the Veteran has had some degree of malnutrition due to Crohn’s disease and his ileal resection surgeries throughout the period on appeal, as required for a 60 percent rating under Diagnostic Code 7323. The Board finds the Veteran’s symptoms and impairment have more nearly approximated the severe symptoms contemplated by Diagnostic Code 7323 for the entire period on appeal, with numerous attacks of Crohn’s disease per ear and malnutrition, with health only fair during remissions, that is when the Veteran is not experiencing a Crohn’s disease exacerbation. However, a 100 percent rating is not warranted. The Board acknowledges that the September 2015 private intestinal conditions DBQ indicates the Veteran’s Crohn’s disease caused marked malnutrition, anemia, and general debility, which are the criteria for a 100 percent rating under Diagnostic Code 7323. However, as explained above, the remaining private and VA examination reports shows the Veteran’s symptoms more consistently approximated the criteria for a 60 percent rating under Diagnostic Code 7323. The September 2015 private intestinal surgery DBQ shows symptoms more closely approximating a 60 percent evaluation under Diagnostic Code 7323. In particular, the examining physician noted chronic fatigue and malaise with nausea, with the resection of the small intestine causing definite interference with absorption and nutrition rather than marked interference. Pertinently, the December 2019 VA examiner determined the Veteran’s noted no malnutrition or general debility caused by the Crohn’s disease. The examiner did note that the Veteran lost 2 to 5 pounds during monthly Crohn’s flares, and the Board accepts a degree of malnutrition and weight loss caused by the Crohn’s disease. He has also been shown to have at least one period of anemia attributable to his Crohn’s disease. See, e.g., September 2014 Private Colonoscopy Report. However, there is no other evidence showing the level of marked malnutrition, anemia, and general debility required for a 100 percent rating. Pertinently, the December 2019 examiner noted no malnutrition, anemia, or general debility. See December 2019 VA Intestinal Conditions Examination Report. Put another way, the Veteran’s symptoms more closely approximated the criteria for a 60 percent rating under Diagnostic Code 7323 during the period on appeal. No information contained in VA or private treatment records suggests the Veteran’s Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm manifested in the level of pronounced symptoms resulting in marked malnutrition, anemia, and general debility contemplated by a 100 percent rating. The Board has also considered whether a higher rating is warranted under Diagnostic Code 7345. A 100 percent rating requires near-constant debilitating symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain. The Board notes that the Veteran’s Crohn’s disease has been rated by analogy under hyphenated Diagnostic Code 7323-7345. However, Diagnostic Code 7345 applies to chronic liver disease without cirrhosis, excluding hepatitis C. Regardless, the Board finds that the Veteran’s symptoms have not been debilitating in nature as contemplated by a 100 percent rating under Diagnostic Code 7345. The Veteran’s abdominal pain and fatigue have been near constant for most of the period on appeal. However, he has been able to perform activities of daily living and, despite issues due to daily fatigue, generally has been able to function to some degree. The Board also notes that the June 2013 private DBQ and December 2019 VA examination report show the Veteran’s Crohn’s disease resulted in incapacitating episodes during the past 12 months of 6 weeks or more, meeting the requirements for a 60 percent rating under Diagnostic Code 7345. The Board notes that the claims file contains no documentation of any prescribed bed rest by a medical treatment provider, and that the Veteran also has not reported such prescription by either his private or VA physicians. However, the Board has determined that a 60 percent rating is appropriate for the entire period on appeal under Diagnostic Code 7323, and the regulations do not allow a separate rating under Diagnostic Code 7345. The Board has considered whether the Veteran would be entitled to a higher rating under any other potentially applicable Diagnostic Code found in 38 C.F.R. § 4.114. However, there is no alternative Diagnostic Code that would afford the Veteran a greater rating for his Crohn’s disease. As noted above, the schedule of ratings for the digestive system, to include Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. See 38 C.F.R. § 4.114. A single evaluation will be assigned under the DC that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. A higher rating under one of those Diagnostic Codes might be possible. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. Esteban, 6 Vet. App. at 261- 62. The Veteran has had cirrhosis of the liver during the applicable time period and, as such, a higher rating under Diagnostic Code 7312 was contemplated, but the Veteran has not had jaundice, ascites, hepatic encephalopathy, or hemorrhage that would warrant a higher rating under that Diagnostic Code. The evidence suggests that the Veteran’s cirrhosis manifests primarily as fatigue and malaise, which overlap significantly with his Crohn’s disease symptomatology. In addition, a separate rating under Diagnostic Code 7312 is not permitted under the regulations. There is evidence that the Veteran has experienced alternating diarrhea and constipation during the period on appeal, and most recently has experienced bouts of severe diarrhea with more or less constant abdominal distress. These symptoms are specifically contemplated by Diagnostic Code 7319, but a rating higher than 30 percent is not available. Furthermore, a separate rating under Diagnostic Code 7319 is not permitted under the regulations. The Veteran has undergone resections of the small and large intestines, implicating Diagnostic Codes 7328 and 7329. The Board notes that the Agency of Original Jurisdiction considered the criteria under Diagnostic Code 7328 in the July 2020 SSOC. A 60 percent rating is the maximum available under Diagnostic Code 7328, which requires marked interference with absorption and nutrition, manifested by severe impairment of health objectively supported by examination findings including material weight loss. At most, the Veteran has been found to have definite interference with absorption and nutrition, criteria for a 40 percent rating. A 40 percent rating the maximum available under 7329. Again, separate ratings under either Diagnostic Code 7328 or 7329 are not permitted under the regulations. A separate rating is permitted under Diagnostic Code 7330, but the Veteran has not had a fistula of the intestines during the appellate period. Finally, the Veteran seeks a separate rating under Diagnostic Code 7332 for occasional involuntary bowel movements necessitating wearing an absorbent pad. The Board has considered the Veteran’s lay statements that he frequently wears adult diapers at night and that he has had occasional involuntary bowel movements due to his Crohn’s disease. Diagnostic Code 7332 applies specifically to impairment of sphincter control of the rectum and anus. There is currently nothing in the record that establishes an anus or rectum pathology or that such should be service connected at this time. If the Veteran believes he is entitled to service connection for a disability of the anus or rectum, the Veteran is informed that he must file a proper claim for service connection on the appropriate form. The Board has considered all other potentially applicable diagnostic codes and regulations. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Board finds no provision upon which to assign a rating greater than 60 percent for the Veteran’s Crohn’s disease with right partial colectomy and terminal ileum resection, and pancreatic neoplasm. The Board also concludes that the Veteran’s symptomatology has been largely consistent throughout the appellate period and assignment of staged ratings is not warranted. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morse The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.