Digestive

GERD (Acid Reflux) C&P Exam Guide

Associated DBQ Form: DBQ Esophageal Conditions

What to Expect During Your Exam

The GERD C&P exam is typically brief (15-20 minutes) and focuses on your symptoms and their impact on daily life.

The exam includes:
1. Review of your diagnosis and medical history
2. Discussion of current symptoms
3. Assessment of treatment and its effectiveness
4. Evaluation of impact on nutrition and weight
5. Review of any diagnostic testing (endoscopy, pH monitoring)

Questions the Examiner May Ask

  • 1 How often do you experience heartburn or acid reflux?
  • 2 Do you have difficulty swallowing?
  • 3 Do you regurgitate food or liquid?
  • 4 Do you have chest pain related to GERD?
  • 5 Does GERD affect your sleep?
  • 6 What medications do you take for GERD?
  • 7 Have you had an endoscopy?
  • 8 Have you experienced unintentional weight loss?
  • 9 What dietary restrictions do you follow?

Documentation to Bring

  • Medical records confirming GERD diagnosis
  • Endoscopy results (if available)
  • pH monitoring studies (if performed)
  • Documentation of medications and treatments
  • Service treatment records showing GI complaints
  • Records of weight changes

How to Prepare

Before your exam:

1. **Document symptom frequency** - How often do you have reflux? Daily? Multiple times per day?

2. **List all symptoms** - Heartburn, regurgitation, difficulty swallowing, chest pain, nausea

3. **Know your medications** - Names, dosages, how long you've taken them

4. **Note dietary restrictions** - Foods you avoid, eating schedule changes

5. **Track any weight changes** - GERD affecting nutrition can impact rating

Helpful Tips

- Be specific about how often symptoms occur
- Mention if GERD disturbs your sleep (having to sleep elevated)
- Describe dietary restrictions you follow because of GERD
- Report any difficulty swallowing or food getting stuck
- If you've had an endoscopy showing esophagitis, mention it
- Discuss how effective your medications are
- Mention any weight loss or nutritional impacts

Common Mistakes to Avoid

- Claiming severe symptoms with no treatment records
- No documentation of diagnosis
- Inconsistency between claimed severity and treatment level

How VA Rates This Condition

GERD is typically rated by analogy under 38 CFR § 4.114:

**Hiatal Hernia (DC 7346) - commonly used for GERD:**

**10%** - Two or more of these symptoms of less severity: persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain

**30%** - Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health

**60%** - Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health

**Key terms:**
- Dysphagia = difficulty swallowing
- Pyrosis = heartburn