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Updated Apr 01, 2024

In This Section

 
This section contains the following topics:
 
Topic
Topic Name
1
2
3
4 Open-Ended Hospitalization Ratings
 

 

  

1.  General Information on Hospitalization Ratings

 

Introduction

 
This topic contains general information on hospitalization ratings under 38 CFR 4.29, including

Change Date

 
July 29, 2021

VIII.iv.8.B.1.a.  When to Assign Hospitalization Ratings

 
Provided a total, 100-percent rating cannot be assigned under other provisions of the rating schedule, assign a temporary 100-percent evaluation under 38 CFR 4.29 for
  • periods of hospitalization at a Department of Veterans Affairs (VA) or an approved hospital or hospital observation at VA expense in excess of 21 days for medical treatment of a service-connected (SC) disability, or
  • a disability requiring hospitalization in excess of 21 days for medical treatment for which compensation is payable under either 38 U.S.C. 1151 or 38 U.S.C. 1160.   
Notes:
  • Competency must be addressed when assigning a temporary 100-percent evaluation for a mental disorder under 38 CFR 4.29.
  • Hospitalization in a uniformed services facility (also known as military treatment facility) is considered an approved hospitalization for the purpose of determining entitlement to a temporary evaluation under 38 CFR 4.29.
References:  For more information on

VIII.iv.8.B.1.b.  Scope of Hospitalization Ratings

 
A hospital rating under the provisions of 38 CFR 4.29 can be prompted based on receipt of a specific claim from a Veteran or based on receipt of a Report of Hospitalization at a VA hospital. 
  • A prescribed form is not required for the purposes of adjudicating entitlement to hospitalization benefits when VA receives a Report of Hospitalization at a VA hospital.  However, receipt of a Report of Hospitalization will result in a rating decision only when entitlement to a temporary rating is warranted.
  • If a Report of Hospitalization at a VA hospital is received, but entitlement to hospitalization benefits is not warranted
    • do not formally deny entitlement by rating decision, and
    • follow the procedures in M21-1, Part X, Subpart iii, 1.A.2.c for disposition of the pending EP and annotation of the claims folder.
  • If a claim for increase is received for an SC disability and the evidence shows entitlement to a hospitalization rating for the same disability, award a temporary total evaluation under the provisions of 38 CFR 4.29 as part of the claim for increase.
  • A claim from a Veteran specifically for a hospitalization rating is not a claim for increase.  However, when the evidence establishes entitlement to a hospitalization rating, whether prompted by a claim from a Veteran or receipt of a Report of Hospitalization, the assignment of a post-hospitalization evaluation is a part of the process of rating the hospitalization issue.
    • An increased evaluation may be warranted and awarded following the period of hospitalization.
    • A reduced evaluation may be warranted by the evidence following the period of hospitalization, and reduction action should be taken in compliance with 38 CFR 3.105(e), as warranted. 
    • If the medical evidence does not establish that a change in the post-hospitalization evaluation is warranted, assign the evaluation in effect prior to hospitalization.  If the medical evidence suggests improvement may occur but such improvement is not definitively established, consider scheduling a routine future examination.
    • The assigned evaluation prior to the hospitalization is not subject to review as a part of the hospitalization rating.
  • When a claim for hospitalization submitted by a Veteran must be denied, do not routinely address the evaluation of the SC issue unless a separate claim for increase has been received.
Reference:  For more information on claims based on reports of examination or hospitalization, see M21-1, Part II, Subpart iii, 2.D.

VIII.iv.8.B.1.c.  When the Provisions of 38 CFR 4.29 Do Not Apply

 
Do not apply the provisions of 38 CFR 4.29 when a Veteran is
  • treated as a resident in a State Veterans’ home
  • currently receiving a total rating for the disability for which hospitalization was required
  • a resident in a VA domiciliary program, or
  • a participant in a live-in/work-out program being utilized to facilitate transition to community living. 
Exceptions: 
  • Hospitalization in excess of 21 days for an SC disability in a medical facility located at a State Veterans’ home may entitle the Veteran to hospitalization benefits.
  • Veterans are entitled to hospitalization benefits for treatment in excess of 21 days in a day hospital program if the treatment given is consistent with hospital care for an SC disability even though they are concurrently required to be housed in a VA domiciliary. 
Notes: 
  • A 100-percent evaluation under 38 CFR 4.29 in combination with another SC disability, independently rated 60 percent or more disabling, entitles the Veteran to statutory Housebound benefits under 38 U.S.C. 1114(s).
  • Hospital care, for the purpose of 38 CFR 4.29, is defined as the provision of services unique to the course of hospitalization for an SC disability.  
  • Domiciliary care
    • means the furnishing of
      • a temporary home to a Veteran, embracing the furnishing of shelter, food, clothing, and other comforts of home, including necessary medical services, or
      • a day hospital program consisting of intensive supervised rehabilitation and treatment provided in a therapeutic residential setting for residents with mental health or substance use disorders, and co-occurring medical or psychosocial needs such as homelessness and unemployment, and
    • includes travel and incidental expenses pursuant to 38 CFR 70.10.  
References:  For more information on

VIII.iv.8.B.1.d.  Awarding Hospitalization Benefits When Admission Is for an NSC Disability

 
When reviewing hospital reports, it is imperative that claims processors review the entire report and not simply the admission or discharge diagnosis.  Even when hospital admission is for a nonservice-connected (NSC) disability, hospitalization benefits are payable if, during the hospitalization, treatment for an SC disability is initiated and continues in excess of 21 days.
 
Exception:  Treatment for an SC disability that is only coincidental in nature and would not require hospitalization by itself does not qualify.
 
Example:  Medication management for a condition when treatment could otherwise occur outside of hospitalization does not warrant benefits under 38 CFR 4.29.
 
Reference:  For more information on hospitalization ratings when admission is for treatment of an NSC disability, see 38 CFR 4.29(b).
  

2.  Effective Dates and Duration for Hospitalization Ratings

 

Introduction

 
This topic contains guidance on effective dates and duration for hospitalization ratings under 38 CFR 4.29, including

Change Date

 
July 29, 2021

VIII.iv.8.B.2.a. Effective Dates of Hospitalization Ratings

 
Use the table below to determine the effective date of hospitalization ratings.
 
When …
Then make the 100-percent rating effective the …
considering
  • any VA hospitalizations, or
  • non-VA hospitalizations, if approved by VA on or before the date of admission
date of hospital admission.
a period of hospitalization at a VA or VA-approved hospital occurs entirely within a single month with no requirement for convalescence
first day of hospitalization.
 
Important:  Payment will commence on the first day of the month in which the hospitalization or treatment began, as provided in 38 CFR 3.31(c)(5) and M21-1, Part X, Subpart iii, 1.B.2.a.  This provision is an exception to the general rule which normally requires that payment commences the first day of the month following the month in which the award became effective.
 
Example:  The Veteran is hospitalized at a VA medical center for an SC condition from March 4, 2014, to March 28, 2014.  The rating activity will grant a temporary 100-percent evaluation effective March 4, 2014, through March 31, 2014.  The authorization activity will adjust the award, as necessary, to pay from the first day of the month of hospitalization.  Resume the schedular evaluation April 1, 2014.
hospitalization at a VA or VA-approved hospital occurs for an NSC disability, but service connection (SC) for the disability requiring hospitalization is established during the course of the hospitalization
date of hospital admission, if otherwise in order, as discussed in
hospitalization at a VA or VA-approved hospital is for an NSC disability but, during the course of hospitalization, hospital treatment for an SC disability is instituted and continued for a period in excess of 21 days
first day of hospital treatment for the SC disability.
 
References:  For more information on

VIII.iv.8.B.2.b.  Duration of Awards Under 38 CFR 4.29

 
Continue the 100-percent rating under 38 CFR 4.29 through the last day of the month in which hospitalization or treatment for the SC disability(ies) terminates.
 
Notes: 
  • Such termination may be due to
    • hospital discharge, regular or irregular, or
    • the cessation of treatment or observation for SC disabilities prior to discharge from the hospital.
  • The effective date for a temporary total evaluation under 38 CFR 4.29 commences from the date of entrance into the hospital, after 21 days of continuous hospitalization or treatment.  
Reference:  For more information on the effective date for temporary total ratings under 38 CFR 4.29, see

VIII.iv.8.B.2.c.  Duration of Extensions of Hospitalization Ratings Allowed Under 38 CFR 4.29

 
The 100-percent rating may initially be extended for 1 month, 2 months, or 3 months, based on a need for convalescence, only when the Veteran received an approved discharge from the hospital. 
 
Following discontinuance of the temporary 100-percent rating, assign the appropriate schedular evaluation for any residual disability.
 
Notes: 
  • It is permissible to initially assign a one-month convalescence period and extend it another one or two months, if the facts warrant it.
  • Further extensions of one or more months, up to three months, may be made upon approval of the Veterans Service Center Manager.
   
 

3.  Special Considerations for Hospitalization Ratings
 

 

Introduction

 
This topic contains special considerations for hospitalization ratings under 38 CFR 4.29, including

Change Date

 
April 1, 2024

VIII.iv.8.B.3.a.  Awarding a Hospitalization Rating for Admission of an Incarcerated Veteran

  
If an incarcerated Veteran is confined to a prison hospital for treatment of an SC disability in excess of 21 days, the Veteran may be eligible for hospitalization benefits.
 
Reference:  For more information on the effect of imprisonment on benefit payments, see M21-1, Part VI, Subpart iii, 1.A.

VIII.iv.8.B.3.b.  Awarding a Hospitalization Rating for Multiple SC Conditions

 
In cases in which two or more SC disabilities exist for which the provisions of 38 CFR 4.29 would apply, increase the evaluation of only one of the disabilities to 100 percent.

VIII.iv.8.B.3.c.  Considering Mental Health Treatment Programs for Hospitalization Ratings

  
For the purpose of determining entitlement to a temporary total evaluation for hospitalization, the decision maker should focus on what types of services the Veteran received and not whether one specific type of program would qualify for benefits.  
  • Only treatment consistent with hospital care warrants an award of benefits under 38 CFR 4.29. 
  • When a Veteran is in in-patient or out-patient care under a Veterans Health Administration (VHA) mental program and is receiving specialized mental health treatment, VHA notifies the regional office through a Report of Hospitalization.  Receipt of a Report of Hospitalization is sufficient to establish that hospital care was provided. 
Note:  Effective October 25, 2018, the regulatory definition of domiciliary care (included in M21-1, Part VIII, Subpart iv, 8.B.1.c) was updated to reflect that VHA’s Mental Health Residential Rehabilitation Treatment Program (MH RRTP) is a type of domiciliary care.

VIII.iv.8.B.3.d.  Considering Treatment Provided During a Domiciliary Stay for Hospitalization Ratings

 
If, while a resident in a VA domiciliary program, the Veteran receives treatment consistent with hospital care for an SC disability and such treatment continues in excess of 21 days, a hospitalization rating under the provisions of 38 CFR 4.29 may be established, if otherwise in order. 
 
Important: 
  • Only treatment consistent with hospital care warrants an award of benefits under 38 CFR 4.29.  Residence in a domiciliary program, in and of itself, does not qualify. 
  • Treatment for an SC disability that is only coincidental in nature and would not require hospital care by itself does not qualify.
  • Treatment for an SC disability that is determined to be consistent with hospital care must exceed 21 days in order to qualify for a temporary total evaluation under 38 CFR 4.29.  It is the length of the hospital treatment (or treatment consistent with hospital care) that is determinative, not the length of the domiciliary stay itself. 
  • After treatment consistent with hospital care for an SC disability has continued in excess of 21 days, the effective date of the 100-percent rating is the first day of such treatment.
Notes:
  • Receipt of a Report of Hospitalization is sufficient to establish that services meeting the definition of hospital care were provided.
  • If a Report of Hospitalization is not received, review the available evidence to determine if the care provided was unique to a course of hospitalization.  In such cases, if it is unclear from the evidence, development may be warranted to ask the hospital for a description of the services that were provided, so that a determination may be made as to whether or not those services were consistent with hospital care.
Reference:  For more information on the definitions of hospital care and domiciliary care, see M21-1, Part VIII, Subpart iv, 8.B.1.c. 
   

4.  Open-Ended Hospitalization Ratings

 

Introduction

 
This topic contains guidance on open-ended hospitalization ratings under 38 CFR 4.29, including

Change Date

 
July 29, 2021

VIII.iv.8.B.4.a.  Preparing an Open-Ended Hospitalization Rating Decision

 
Open-ended ratings under 38 CFR 4.29 may be established only for hospitalization in a VA hospital.
  • For VA hospitalizations, automated reporting functionality, as discussed in M21-1, Part X, Subpart iii, 1.A, will result in creation of a follow-up end product (EP) for discontinuation of the open-ended rating when the Veteran is discharged.
  • For hospitalizations at a military treatment facility or other approved hospitals, do not prepare an open-ended rating.  If the hospitalization continues at the time the rating decision is issued,
    • establish a temporary 100-percent rating when the evidence shows hospitalization in excess of 21 days for an SC disability
    • extend the temporary 100-percent rating through the last day of the month of the known period of hospitalization, and
    • notify the Veteran that if the hospitalization continues beyond that date, evidence documenting the date of discharge or the requirement for continuing hospitalization should be submitted for an extension of the hospitalization period.
Reference:  For more information on preparing hospitalization rating decisions in the Veterans Benefits Management System – Rating (VBMS-R), see the VBMS-R User Guide.

VIII.iv.8.B.4.b.  Follow-up on Open-Ended Hospitalization Evaluations

 
When an open-ended hospitalization evaluation remains pending for a VA hospitalization, the running evaluation under 38 CFR 4.29 will cause an 800 series work item with the following message code to be generated every three months:  884 Paragraph 29 Over 3 Months.
 
It is the authorization activity’s responsibility to determine whether the Veteran continues to be hospitalized.  An EP 320 will be established, and the claims folder will be referred to the rating activity for consideration of a schedular 100-percent rating or reduction, as appropriate, when a Veteran
  • remains hospitalized for more than six months, or
  • is no longer hospitalized.
Notes: 
  • 800 series work items are for tracking purposes only.  Do not complete development, rating, or award actions under an 800 series work item.
  • Do not routinely schedule an examination to evaluate the disability for which the hospitalization occurred.  Conduct an examination only when the evidence is insufficient to evaluate the disability. 
References:  For more information on

VIII.iv.8.B.4.c.  Discontinuance of Open-Ended Hospitalization Evaluations

 
When following up on an open-ended hospitalization rating decision
  • request a reexamination
    • only if needed to properly evaluate the post-hospitalization level of impairment, and
    • sufficiently in advance of the anticipated date of discharge to ensure receipt of the report prior to expiration of the temporary 100-percent rating
  • continue the 100-percent evaluation in cases in which the Veteran immediately enters into a day hospital program following inpatient hospitalization in excess of 21 days for psychiatric illness, as this action indicates that the Veteran is still in need of treatment and not able to return to employment. 
Upon receipt of the discharge report, reexamination report, or cessation of treatment in the day hospital program, assign an applicable schedular evaluation for the residuals.
 
Note:  Do not apply the provisions of 38 CFR 3.105(e) unless the evaluation in effect prior to hospitalization is reduced following assignment of the 100-percent rating.  
 
References:  For more information on