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C&P Exam Prep: Crohn's Disease / Inflammatory Bowel Disease

DC 7326 digestive 38 CFR 4.114

DBQ Overview

Interview + Physical
Form Name
intestines
Form Code
intestines
Page Count
11
Examiner Type
Gastroenterologist or Physician
Estimated Duration
20-30 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of your Crohn's Disease or other inflammatory bowel disease (IBD) for VA disability rating purposes under 38 CFR - 4.114, DC 7326. The examiner will assess your symptoms, treatment, hospitalizations, nutritional status, systemic manifestations, and functional impairment to assign an appropriate disability rating.

What the examiner evaluates:

  • Current diagnosis and confirmation via endoscopy or radiologic studies (required under DC 7326 Note 3)
  • Frequency and severity of diarrhea episodes per day
  • Presence of rectal bleeding and frequency
  • Signs of systemic toxicity including fever, tachycardia, anemia, and elevated white blood cell count
  • Nutritional status including BMI, need for prescribed dietary supplementation, enteral (tube) feeding, or total parenteral nutrition (TPN)
  • Hospitalization history and frequency (at least once per year threshold is significant)
  • Surgical history including colectomy, ileostomy, resection of small or large intestine, or permanent colostomy
  • Current medications including immunosuppressants, biologics, corticosteroids, and oral/topical agents
  • Presence of complications such as fistulous disease, abscess, peritonitis, obstruction, hemorrhage, or perforation
  • Systemic manifestations including weakness/fatigue, dermatitis, lymph node enlargement, hypocalcemia, low vitamin levels, and anemia related to malabsorption
  • Ability to work and functional impact on daily activities
  • Whether condition is managed by ambulatory care only or requires recurrent emergency treatment

The exam will likely include a brief abdominal physical examination and an in-depth interview about your symptoms, treatment history, and functional limitations. Bring all relevant medical records, lab results, colonoscopy/endoscopy reports, and a written symptom summary. The examiner is completing the GI Intestines DBQ and their documentation directly drives your rating. You have the right to record this examination in most states - notify the examiner at the start if you wish to do so.

Typical duration: 20-30 minutes

Bowel Movement Frequency Count

Number of loose or watery bowel movements per day, which is a primary rating driver under DC 7326. The examiner will document daily diarrhea frequency and whether episodes are watery, bloody, or explosive.

What to expect:

The examiner will ask how many bowel movements you have per day on average, on your worst days, and during flares. Be prepared to give a range (e.g., 3-8 per day) and describe whether urgency, incontinence, or explosive episodes occur.

Key thresholds:

  • Daily diarrhea present — Supports 10-30% rating; frequency and associated symptoms drive the level
  • 4 or more episodes of diarrhea per day — Key threshold for higher-level consideration under DC 7326; supports 30-60% range
  • 6 or more episodes per day of rectal bleeding — Critical threshold supporting 60%+ rating with other severity indicators
  • Explosive/unpredictable bowel movements — Supports functional impairment documentation and higher ratings

Tips:

  • Track your daily bowel movement count in a symptom diary for at least 4 weeks before the exam
  • Report your worst-day frequency, not just your average - M21-1 guidance supports reporting worst-day symptom severity
  • Describe whether movements are watery, bloody, mucus-containing, or explosive
  • Note how often you experience fecal urgency so severe you cannot delay reaching a restroom
  • Report any episodes of fecal incontinence, even if rare

Pain considerations: Abdominal cramping and pain that precedes or accompanies bowel movements should be described in detail, including location, intensity (1-10 scale), duration, and whether it wakes you at night.

BMI and Nutritional Status Assessment

Body Mass Index (BMI) and evidence of malnutrition, undernutrition, or weight loss - directly linked to rating thresholds for DC 7326 and related codes.

What to expect:

The examiner will measure your height and weight and calculate your BMI. They will ask about unintentional weight loss, dietary restrictions, use of prescribed nutritional supplements, enteral feeding, or TPN.

Key thresholds:

  • BMI 16-18 (inclusive) — Supports higher severity rating; documented undernutrition
  • BMI less than 16 — Severe undernutrition threshold; supports highest rating levels
  • Requiring prescribed oral dietary supplementation — Documents need for nutritional intervention; relevant to moderate-to-severe ratings
  • Requiring total parenteral nutrition (TPN) — Significant severity indicator; continuous TPN supports 100% rating consideration

Tips:

  • Document all prescribed nutritional supplements (e.g., Ensure, Boost, Modulen) - include prescription documentation
  • Report any foods you cannot eat due to your condition and how this limits your diet
  • Note any significant unintentional weight loss over the past year with specific amounts
  • If you have had periods of tube feeding or TPN, bring documentation with dates

Pain considerations: Eating-related pain (post-prandial cramping, fear of eating due to pain) directly affects nutritional intake and should be clearly communicated as a driver of weight loss and dietary restriction.

Laboratory Values Review (CBC, Inflammatory Markers)

The examiner reviews blood work including complete blood count (hemoglobin, hematocrit, WBC, platelets), serum antibody tests (ASCA, p-ANCA), and other markers to document active disease, anemia, leukocytosis, and systemic inflammation.

What to expect:

The examiner will review any recent lab results in your file. Bring printed copies of recent labs (within 12 months) including CBC, CRP, ESR, albumin, vitamin B12, iron studies, and any IBD-specific serology.

Key thresholds:

  • Anemia (low hemoglobin/hematocrit) — Systemic toxicity sign; supports signs-of-toxicity designation and higher ratings
  • Leukocytosis (elevated WBC) — Indicator of active disease/systemic toxicity; supports higher severity
  • Low vitamin levels (B12, D, folate, iron) — Documents systemic manifestation of malabsorption; relevant to rating
  • Hypocalcemia — Documented systemic manifestation; supports severity classification

Tips:

  • Bring printed copies of your most recent lab results - do not assume the examiner has access to all your records
  • Highlight any abnormal values with a brief note explaining they are IBD-related
  • If you have had episodes of anemia requiring treatment, document dates and treatments received
  • Include fecal calprotectin or lactoferrin results if available as evidence of active bowel inflammation

Pain considerations: Anemia caused by chronic blood loss or malabsorption contributes to fatigue and weakness, which should be separately described as a functional limitation.

Endoscopy / Colonoscopy / Radiologic Study Documentation

Per DC 7326, Crohn's Disease must be confirmed by endoscopy or radiologic studies. The examiner will look for biopsy results, colonoscopy findings, MRI enterography, CT scan results, or upper GI series that confirm diagnosis and document extent/location of disease.

What to expect:

The examiner will review diagnostic imaging and procedure reports. Bring copies of all endoscopy/colonoscopy reports with pathology results, CT or MRI enterography reports, and upper GI series reports.

Key thresholds:

  • Active inflammation confirmed on endoscopy/biopsy — Required for diagnosis under DC 7326; documents active disease severity
  • Transmural disease, fistulas, strictures on imaging — Documents complicated disease; supports higher severity ratings and complication coding
  • Atrophy of intestinal lining on biopsy — Supports malabsorption syndrome findings; relevant to systemic manifestation rating

Tips:

  • Bring a complete list of all endoscopic and imaging studies with dates and facilities
  • If you have had multiple colonoscopies, bring the most recent showing active disease
  • MRI enterography reports are especially useful for documenting small bowel Crohn's disease
  • Video capsule endoscopy results are also relevant if you have had them

Pain considerations: Document any post-procedure pain, complications, or worsening of symptoms following diagnostic procedures, as this demonstrates the severity of your underlying disease.

Hospitalization and Emergency Treatment History

Frequency of hospitalizations and emergency department visits due to Crohn's flares, dehydration, obstruction, or other complications. Hospitalization at least once per year is a specific rating threshold.

What to expect:

The examiner will ask how many times you have been hospitalized or visited the emergency room in the past 12 months and prior years. Be prepared with specific dates, locations, and reasons for each admission.

Key thresholds:

  • Hospitalization at least once per year — Specific threshold relevant to 60%+ rating consideration under DC 7326
  • More than 2 episodes of dehydration requiring IV fluids in 12 months — Significant complication indicator supporting higher severity ratings
  • Recurrent emergency treatment for intestinal episodes — Supports higher functional impairment and severity ratings

Tips:

  • Create a written hospitalization log with dates, facility names, duration of stay, and reason for admission
  • Include all emergency department visits even if you were not admitted overnight
  • Document any IV hydration treatments received in outpatient or infusion center settings
  • Note any ICU admissions or surgical interventions during hospitalizations

Pain considerations: Severe pain episodes that drive emergency room visits (e.g., obstruction, acute flares) should be described in detail - note the character, severity, and what interventions were required to control the pain.

Estimate

Rating Criteria Breakdown

100% Very severe - Permanent colostomy; or requiring continuous t ...

Very severe - Permanent colostomy; or requiring continuous total parenteral nutrition (TPN) for a period longer than the anticipated recovery period; or requiring complete dependence on TPN; or short bowel syndrome with high-output syndrome; or other manifestations requiring complete dependence on parenteral nutrition.

Key Symptoms

  • Permanent colostomy
  • Requiring continuous TPN for extended period
  • Complete dependence on total parenteral nutrition
  • Short bowel syndrome with high-output syndrome
  • Requiring tube feeding for nutritional support
  • BMI less than 16
  • Formation of ileostomy
  • Colectomy (total)

CFR: The 100% rating under DC 7326 reflects the most severe disease manifestations including permanent surgical diversions, complete nutritional dependence on TPN, or short bowel syndrome with high-output syndrome demonstrating that oral nutrition is insufficient to sustain the body.

60% Severe - Requiring hospitalization at least once per year; o ...

Severe - Requiring hospitalization at least once per year; or requiring surgical intervention; or with serious systemic manifestations (fever, tachycardia, anemia); or resulting in an inability to work. Six or more episodes per day of rectal bleeding, or other severe complications.

Key Symptoms

  • Hospitalization required at least once per year
  • Six or more episodes per day of rectal bleeding
  • Signs of systemic toxicity: fever, tachycardia, anemia
  • Requiring prescribed oral dietary supplementation
  • More than 2 episodes of dehydration requiring IV fluids
  • Results in inability to work
  • External intestinal fistulous disease
  • Recurrent emergency treatment for intestinal episodes

CFR: At the 60% level under DC 7326, the condition requires hospitalization at least annually, demonstrates systemic toxicity, or significantly impairs the ability to work. Complications such as fistulous disease and recurrent emergency care distinguish this level.

30% Moderately severe - Managed on an outpatient basis with immu ...

Moderately severe - Managed on an outpatient basis with immunosuppressants or biologics. Signs of mild systemic toxicity may be present. Daily diarrhea, recurrent abdominal pain, and other GI symptoms present. May require prescribed dietary management.

Key Symptoms

  • Managed on outpatient basis with immunosuppressants or corticosteroids
  • Daily diarrhea present
  • Recurrent abdominal pain
  • Signs of minimal systemic toxicity (mild fever, mild anemia)
  • Requiring prescribed dietary management or manipulation
  • Weakness and fatigue

CFR: At the 30% level, DC 7326 requires outpatient management with immunosuppressants or biologics, reflecting more severe disease requiring stronger medications. Daily diarrhea and systemic symptoms distinguish this from the 10% level.

10% Moderate - Requiring continuous medication for control. Symp ...

Moderate - Requiring continuous medication for control. Symptoms are present but manageable with oral or topical agents other than immunosuppressants. No signs of systemic toxicity. Condition managed without hospitalizations.

Key Symptoms

  • Requiring continuous medication for symptom control
  • Managed with oral or topical agents other than immunosuppressants
  • No signs of systemic toxicity (no fever, tachycardia, or anemia)
  • Intermittent diarrhea or abdominal pain
  • No hospitalizations required

CFR: Under 38 CFR - 4.114 DC 7326, the 10% level corresponds to disease requiring continuous medication but without systemic toxicity, hospitalizations, or need for immunosuppressants. Ulcerative colitis (DC 7323) and chronic enteritis (DC 7325) rate identically under DC 7326.

How to Describe Your Symptoms

Diarrhea Frequency and Character

How to describe:

Describe the exact number of bowel movements on your average day versus your worst day. Specify whether stools are watery, loose, mucus-containing, or bloody. Describe urgency - how quickly you must reach a restroom after feeling the urge. Note any episodes of fecal incontinence. Report whether this occurs at night, disrupting sleep.

Worst-day example:

“On my worst days during a flare, I have 8 to 10 watery bowel movements. The urgency is so severe that I have had accidents before reaching the restroom. I am up 3 to 4 times per night with diarrhea, and I cannot sleep more than 2 hours at a stretch. I am afraid to leave my home on those days because public restrooms are not always available quickly enough.”

What the examiner listens for:

Specific number of episodes per day (especially 4+ and 6+), presence of rectal bleeding, description of urgency and incontinence, nocturnal symptoms, and how diarrhea affects ability to work and perform daily activities.

Understatements to avoid:

Do not say 'I have frequent diarrhea' without giving a number. Do not only report your average day - your worst days are equally important. Do not minimize urgency or incontinence out of embarrassment; these are medically significant symptoms.

Abdominal Pain and Cramping

How to describe:

Describe the location (right lower quadrant, periumbilical, diffuse), character (cramping, sharp, constant, colicky), intensity on a 1-10 scale, duration, and triggers (eating, stress, certain foods). Note whether pain wakes you at night and whether it has prevented you from eating. Describe how pain affects your ability to work, exercise, or perform activities of daily living.

Worst-day example:

“During flares, I have severe cramping in my right lower abdomen rated 8 out of 10. It begins within 30 minutes of eating anything, which causes me to avoid eating to prevent the pain. I have missed work multiple times because the pain is so severe I cannot stand upright. At night the pain wakes me 2 to 3 times, and I have gone to the emergency room twice in the past year because the pain was uncontrollable at home.”

What the examiner listens for:

Pain severity ratings, connection to eating (post-prandial pain), whether pain prevents normal activities, whether pain has driven emergency visits or hospitalizations, and whether current medications adequately control the pain.

Understatements to avoid:

Do not say 'I have some stomach pain' - quantify it. Do not say your pain is 'manageable' if you are limiting activities to manage it. Do not fail to mention pain that only occurs during flares; flare severity is critical to rating.

Fatigue and Weakness

How to describe:

Describe how fatigue from your Crohn's disease affects your ability to work, exercise, perform household tasks, and engage in social activities. Note whether fatigue is present even on days without active diarrhea. Describe the relationship between disease activity, anemia, and your energy level.

Worst-day example:

“My Crohn's fatigue is completely different from normal tiredness. On bad days I cannot get off the couch. I have had to call out of work because I am too exhausted to function. Even when I am not flaring, I have a baseline fatigue that limits how much I can do in a day. I used to run 3 miles daily before my diagnosis; now I cannot walk a mile without needing to rest.”

What the examiner listens for:

Whether fatigue is attributable to the GI condition (versus other causes), its impact on employment and daily functioning, and whether it is associated with documented anemia or malnutrition.

Understatements to avoid:

Do not minimize fatigue as something you 'push through.' Do not fail to connect fatigue to anemia, malabsorption, or disrupted sleep caused by nocturnal diarrhea. Report the specific activities you can no longer perform.

Systemic Manifestations and Extra-Intestinal Complications

How to describe:

Crohn's disease can affect organs beyond the gut. Describe any skin conditions (pyoderma gangrenosum, erythema nodosum), joint pain (arthritis), eye inflammation (uveitis, episcleritis), liver disease (primary sclerosing cholangitis), mouth sores, and any other systemic symptoms. These must be reported as they can be rated separately or increase overall disability.

Worst-day example:

“During flares I also develop painful skin lesions on my legs, my joints ache so severely I cannot open jars or climb stairs, and I get painful mouth sores that prevent me from eating. My rheumatologist confirmed the joint disease is related to my Crohn's. These symptoms hit at the same time as my bowel symptoms and together make me completely non-functional.”

What the examiner listens for:

Documentation of extra-intestinal manifestations that are attributable to IBD, severity and frequency of these complications, and whether they are being separately treated.

Understatements to avoid:

Do not assume the examiner knows about your skin, joint, or eye complications from your file. Proactively mention every extra-intestinal symptom. These may support secondary service connection claims in addition to your primary IBD rating.

Functional and Occupational Impact

How to describe:

Describe specifically how your Crohn's disease limits your ability to work and perform daily activities. Note any accommodations you require at work (proximity to restroom, unpredictable absences, dietary restrictions). Describe activities of daily living you can no longer perform, social activities you avoid, and any job losses or demotions related to your condition.

Worst-day example:

“I have had to negotiate a formal workplace accommodation to sit near the restroom and be allowed to leave meetings without explanation. Despite this, I have missed an average of 3 days per month due to flares over the past year. I declined a promotion because the new role required travel, which I cannot manage due to unpredictable bowel urgency. I no longer attend social events because I cannot guarantee access to a restroom at all times.”

What the examiner listens for:

Specific examples of work absences, job modifications, social isolation, and activities of daily living limitations. The examiner must document functional impact per the DBQ, and your specific examples give them language to use.

Understatements to avoid:

Do not give vague answers like 'it affects my work.' Provide specific numbers (days missed, accommodations made). Do not fail to mention if you have lost a job or been unable to maintain employment due to your condition - inability to work is a 60% threshold marker.

Flare Frequency, Duration, and Triggers

How to describe:

Describe how often you experience flares, how long they typically last, what triggers them (stress, certain foods, infections, stopping medication), and how completely you recover between flares. Note whether you have had a period of complete remission or whether you have persistent baseline symptoms.

Worst-day example:

“I experience major flares approximately every 6 to 8 weeks, each lasting 10 to 14 days. Between flares I still have 3 to 4 loose stools daily and some baseline cramping, so I am never fully well. Stress is a significant trigger - work deadlines reliably worsen my symptoms within 24 hours. During a flare I am largely homebound and must plan every outing around restroom access.”

What the examiner listens for:

Whether disease is truly in remission versus having persistent baseline symptoms, frequency and duration of severe flares, and triggers that are unavoidable (stress, normal dietary variety).

Understatements to avoid:

Do not say you are 'doing okay' between flares if you still have daily symptoms. Do not round down flare frequency. Do not minimize the impact of triggers - if normal stress reliably causes flares, that is a significant functional limitation.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to record your C&P examination in most states - notify the examiner at the start of the exam if you wish to exercise this right. Check your state's consent laws beforehand.
  • You have the right to obtain a copy of the completed DBQ from your VA Regional Office after the exam. Submit a written request as soon as possible after your appointment.
  • Under 38 CFR - 3.159, VA has a duty to assist you in obtaining evidence, including scheduling adequate examinations and providing examiners with relevant records.
  • If the C&P examination is found to be inadequate - for example, if the examiner failed to address all claimed disabilities, did not review relevant records, or provided unsupported conclusions - you have the right to request a new examination.
  • You have the right to submit a personal statement (VA Form 21-4138) or a lay statement describing your symptoms and their functional impact. This becomes part of your official claims file and can supplement or correct incomplete DBQ documentation.
  • You have the right to bring a representative (VSO, accredited claims agent, or attorney) to your C&P examination. The representative typically may not speak during the exam but may be present.
  • Benefit of the doubt applies under 38 CFR - 3.102 - when there is an approximate balance of evidence for and against a claim, VA must resolve the doubt in the veteran's favor.
  • You have the right to submit buddy statements (lay evidence) from family, friends, coworkers, or supervisors who can attest to the observable effects of your disability on your daily functioning. These carry evidentiary weight under Jandreau v. Nicholson.
  • Your condition must be rated based on its full impact including during flares and worst-day manifestations - a rating assigned only based on symptom-free or well-controlled periods does not accurately reflect your average impaired earning capacity.
  • Under 38 CFR - 3.321(b), if your disability is so exceptional or unusual that the rating schedule does not adequately reflect its severity, you may be entitled to an extra-schedular rating - discuss this with your VSO or attorney if your functional limitations far exceed what the rating percentages reflect.
  • DC 7326 requires diagnosis confirmation by endoscopy or radiologic studies per Note 3 - you have the right to ensure the examiner acknowledges your diagnostic confirmation in the DBQ. If they do not, this is a basis for challenging exam adequacy.
  • Ulcerative colitis (DC 7323) and chronic enteritis (DC 7325) are rated identically under DC 7326 - if your condition has been reclassified or if you have more than one IBD condition, ensure the examiner rates using the most favorable applicable code.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.