M21-1 Manual / Part VIII, Subpart iv, Chapter 4, Section A

Special Monthly Compensation (SMC)

M21-1, Part VIII, Subpart iv, Chapter 4, Section A

Overview

In This Section

This section contains the following topics:

Topic	Topic Name
1	General Information on SMC
2	Combining Disabilities When Entitlement to SMC Is at Issue
3	Hospital Adjustments Under 38 CFR 3.552
4	Entitlement to SMC Under 38 U.S.C. 1114(k)
5	SMC for Blindness With Other Disabilities Affecting Hearing and the Extremities
6	SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)
7	Entitlement to Additional SMC for Loss or Loss of Use (L/LOU) of Three Extremities Under 38 CFR 3.350(f)(5)
8	Entitlement to SMC Based on the Need for Aid and Attendance (A&A)
9	Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)
10	Entitlement to Housebound Benefits
11	Entitlement to SMC Under 38 U.S.C. 1114(t) Based on the Need for A&A for Residuals of Traumatic Brain Injury (TBI)
12	Entitlement to Special Monthly Spouse’s Compensation

1. General Information on SMC

Introduction

This topic contains general information on SMC, including

definition of SMC
responsibility for determining loss of use (LOU)
information to request from an examiner to determine LOU
determining the extent of examinations in claims involving SMC under 38 U.S.C. 1114(l) through (n)
considering amputation or LOU of extremities
showing
- entitlement to SMC in rating decisions, and
- the denial of SMC in rating decisions
mandatory use of the SMC Calculator
use of VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, in SMC claims, and
definition of anatomical segment.

Change Date

March 23, 2026

VIII.iv.4.A.1.a. Definition: SMC

Special monthly compensation (SMC) is an additional level of compensation to Veterans (above the basic levels of compensation payable based on disability ratings of 0 to 100 percent) for various types of anatomical losses or levels of impairment due solely to service-connected (SC) disabilities.Reference: For more information on SMC, see
38 U.S.C. 1114, and
38 CFR 3.350.

VIII.iv.4.A.1.b. Responsibility for Determining LOU

The responsibility for determining whether there is loss of use (LOU) of an extremity

rests with the rating activity, and
cannot be delegated to the examining physician.

VIII.iv.4.A.1.c. Information to Request From an Examiner to Determine LOU

When requesting an examination to determine LOU of an extremity, ask the examiner to furnish a

detailed objective description of remaining function
quantitative assessment of strength for each extremity involved, and
description of any pain that affects use.

Do not request that the examiner

determine LOU, or
express an opinion as to whether there is, or is not, LOU of an extremity or extremities.

Note: If LOU cannot be determined upon review of an examination report, request an appropriate specialized examination.References: For more information on
considering functional loss due to pain in claims for SMC, see Tucker v. West, 11 Vet.App. 369 (1998)
requesting a specialist examination, see M21-1, Part IV, Subpart i, 2.A.6, and
avoidance of asking for legal conclusions regarding LOU in a medical opinion request, see M21-1, Part IV, Subpart i, 2.A.7.j.

VIII.iv.4.A.1.d. Determining the Extent of Examinations in Claims Involving SMC Under 38 U.S.C. 1114(l) Through (n)

Exercise considerable care when requesting examinations in connection with claims involving SMC under 38 U.S.C. 1114(l) through (n).Example: A prior examination clearly established LOU of both lower extremities at a level preventing natural knee action. Do not request a complete medical examination if the only issue in question is the extent of involvement of one or both of the upper extremities. Instead, request an examination with a notation that the examination be restricted to the degree of functional impairment of the upper extremities.

VIII.iv.4.A.1.e. Considering Amputation or LOU of Extremities

A determination as to LOU of a hand or foot is not restricted to organic loss; it includes functional LOU as well. The relevant inquiry concerning entitlement to SMC is not whether amputation is warranted. Instead, question whether the effective function remaining is other than that which would be equally well served by an amputation with the use of a suitable prosthetic appliance.References: For more information on
determining entitlement to SMC based on LOU that is equivalent to amputation, see Tucker v. West, 11 Vet.App. 369 (1998), and
LOU of a hand or foot, see 38 CFR 4.63.

VIII.iv.4.A.1.f. Showing Entitlement to SMC in Rating Decisions

Entitlement to SMC must be reflected in the coded conclusion section of the rating decision by

noting entitlement to SMC and statutory awards immediately following citation of the combined evaluation of all SC disabilities (if more than one exists)
listing any anatomical loss as the first entitlement in order of preference over all LOUs, and
citing separately each additional specific disability if entitlement under 38 U.S.C. 1114(k) is shown for more than one anatomical loss, or LOU.

Important: Rating decisions addressing SMC at a rate equal to or greater than SMC (l) require second-signature approval.References: For more information on
SMC codes, see historical M21-1, Part I, Appendix A, Sections V-VIII
SMC payment rates, see Rate Tables
the Codesheet in SMC decisions, see M21-1, Part V, Subpart iv, 1.B.5.a
two-signature requirements for SMC ratings, see M21-1, Part V, Subpart iv, 1.B.7.d, and
protection of SMC ratings, see M21-1, Part X, Subpart ii, 1.B.1.g.

VIII.iv.4.A.1.g. Showing the Denial of SMC in Rating Decisions

The denial of SMC must be addressed in the Narrative of the rating decision using the text generated by the software application with which the rating activity prepares the decision.Note: The generated text should be considered the baseline text for the narrative denial of SMC. The rating activity should edit the generated text as necessary to provide details specific to the individual SMC claim.Important: Rating decisions addressing SMC at a rate equal to or greater than SMC (l) require second-signature approval.Reference: For more information on two-signature requirements for SMC ratings, see M21-1, Part V, Subpart iv, 1.B.7.d.

VIII.iv.4.A.1.h. Mandatory Use of the SMC Calculator

The rating activity must use the SMC Calculator to determine the appropriate SMC codes and SMC paragraphs to input into the Codesheet of the rating decision. Decision makers are required to upload the SMC Calculator results, whether from the legacy tool or the SMC Calculator included in the Veterans Benefits Management System -- Rating (VBMS-R), in the claims folder. When uploading the SMC Calculator worksheet results to VBMS, users should identify the worksheet by entering the following information:
SUBJECT: SMC Calculator Worksheet
TYPE: Worksheet: Rating Calculator Worksheets
SOURCE: VBMS
Notes:
Build the SMC rating narrative using system-generated language, glossary fragments, and free text as appropriate.
Consider any ancillary benefit information generated by the calculator and consider whether additional issues need to be decided.
The calculator must be used anytime a decision addresses SMC and SMC is coded on the Codesheet, including for confirmed and continued decisions.
References: For more information on
using the legacy SMC Calculator, see the SMC Calculator User Guide
using the SMC Calculator in VBMS-R, see the VBMS Rating User Guide
generating the rating narrative, see M21-1, Part V, Subpart iv, 1.A
considering subordinate issues and ancillary benefits, see M21-1, Part V, Subpart ii, 3.A.2.b, and
determining SMC codes and paragraphs when SMC (t) is involved, including when not to use certain results generated by the SMC calculator, see M21-1, Part VIII, Subpart iv, 4.A.11.c.

VIII.iv.4.A.1.i. Use of VA Form 21-2680 in SMC Claims

Medical providers within or outside of the Department of Veterans Affairs (VA) may complete VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, to provide evidence that a claimant is in need of aid and attendance (A&A) and/or housebound benefits. Notes:
Statements by medical providers on VA Form 21-2680 which meet the requirements of 38 CFR 3.326(b) and 38 CFR 3.159(a)(1) are acceptable for rating purposes.
AlthoughVA Form 21-2680may be accepted as a prescribed form adequate to claim entitlement to SMC, this form is not required to develop a claim for or grant entitlement to SMC. Additional development for VA Form 21-2680 should not be routinely undertaken when the form is not received with a claim.
References: For more information on
accepting VA Form 21-2680 as a prescribed form in claims for SMC, see
M21-1, Part II, Subpart iii, 1.A.1.a, and
M21-1, Part II, Subpart iii, 1.A.3.a
issues that arise from consideration of VA Form 21-2680, including the potential for increased evaluation of an SC disability, see M21-1, Part II, Subpart iii, 1.A.3.c, and
processing fully developed claims, see M21-1, Part X, Subpart i, 2.B.

VIII.iv.4.A.1.j. Definition: Anatomical Segment

The term anatomical segmentas used in 38 CFR 3.350 refers to the separate sections of the body that comprise each anatomical region. The term anatomical region, as used in 38 CFR 4.55(b), is not synonymous with anatomical segment, as used in 38 CFR 3.350. The musculoskeletal system within the VA Schedule for Rating Disabilities located at 38 CFR 4.71a is divided into anatomical segments which include the
shoulder and arm
elbow and forearm
wrist
hand
lumbosacral and sacroiliac joints (see notes below)
thoracolumbar spine
cervical spine
hip and thigh
knee and leg
ankle
foot
skull
ribs, and
coccyx.
Notes:
Per 38 CFR 4.66, the lumbosacral and sacroiliac joints are also considered one anatomical segment for rating purposes although they are not specifically listed as a segment within 38 CFR 4.71a.
Note (6) of the General Rating Formula for Diseases and Injuries of the Spine, included within 38 CFR 4.71a, identifies the thoracolumbar and cervical spine as separate segments.
Each extremity includes separate anatomical segments. For example, the right hand and the left hand are separate anatomical segments.
Applying this concept, the anatomical region consisting of the foot and leg, as identified at 38 CFR 4.55(b), includes the following three anatomical segments: the foot, ankle, and knee and leg.
Example: A Veteran is SC for amputation of bilateral feet, evaluated as 100-percent disabling. The Veteran underwent a total knee replacement. Following the temporary total evaluation assigned after knee replacement, the knee is evaluated as 60-percent disabling. SMC (l) is warranted for the bilateral foot amputation, and SMC (p) is warranted under 38 CFR 3.350(f)(3) for the knee disability since it is an additional permanent disability independently evaluated as 50 percent or more. The knee and the foot are separate anatomical segments as is required in 38 CFR 3.350(f)(3) and (4). Since the knee disability involves a separate anatomical segment, the SMC (p) may be assigned in spite of the fact that the disabilities are of a common bodily system.

2. Combining Disabilities When Entitlement to SMC Is at Issue

Introduction

This topic contains information on combining disabilities when entitlement to SMC is at issue, including

when multiple disabilities should not be evaluated as a single disability
evaluating a multisystem disorder
an example of a rating decision involving a multisystem disorder
cases involving loss of anal and bladder sphincter control, and
avoiding separate SMC assignments for L/LOU of an extremity.

Change Date

March 23, 2026

VIII.iv.4.A.2.a. When Multiple Disabilities Should Not Be Evaluated as a Single Disability

Do not rate multiple disabilities as a single disability if there is a possibility of entitlement to
SMC under 38 U.S.C. 1114(s), or
an intermediate or next higher rate of SMC under
38 CFR 3.350(f)(3), or
38 CFR 3.350(f)(4).

VIII.iv.4.A.2.b. Evaluating a Multisystem Disorder

The assignment of a single evaluation of 100 percent for a multisystem disorder, based on LOU of two extremities, may overlook the disorder’s involvement in other body systems. This involvement might meet requirements for

an intermediate rate under 38 CFR 3.350(f)(3), or
the next higher rate under 38 CFR 3.350(f)(4).

VIII.iv.4.A.2.c. Example: Rating Decision Involving a Multisystem Disorder

Situation: A Veteran has lost the use of both lower extremities due to SC multiple sclerosis. Result: Assign
a 100-percent evaluation for the LOU of both lower extremities under hyphenated diagnostic code (DC) 8018-5110, and
separate evaluations under the appropriate DCs for the involvement of any other body system so that possible entitlement to a higher level of SMC will not be overlooked.
Coded Conclusion: SUBJECT TO COMPENSATION (1. SC)8018-5110 MULTIPLE SCLEROSIS, WITH LOSS OF USE BOTH LOWER EXTREMITIES
100 percent from 06/14/2025.6516 DYSARTHRIA, DUE TO MULTIPLE SCLEROSIS
30 percent from 06/14/2025.7332 IMPAIRMENT OF ANAL SPHINCTER CONTROL DUE TO MULTIPLE SCLEROSIS
10 percent from 06/14/2025.7512 LOSS OF BLADDER CONTROL, MODERATE, DUE TO MULTIPLE SCLEROSIS
10 percent from 06/14/2025.6016 NYSTAGMUS DUE TO MULTIPLE SCLEROSIS
10 percent from 06/14/2025.COMBINED EVALUATION FOR COMPENSATION:100 percent from 06/14/2025.SPECIAL MONTHLY COMPENSATIONL-1 Entitled to SMC under 38 U.S.C. 1114(l) and 38 CFR 3.350(b) on account of loss of use of both feet from 06/14/2025.P-1 Entitled to SMC under 38 U.S.C. 1114(p) and 38 CFR 3.350(f)(3) at the rate intermediate between 38 U.S.C. 1114(l) and 38 U.S.C. 1114(m) on account of loss of use of both feet with additional disabilities, dysarthria, loss of bladder control, impairment of anal sphincter control and nystagmus independently ratable at 50-percent or more disabling from 06/14/2025.The appropriate SMC coding is shown in the table below.
EFFECTIVE DATE BASIC HOSPITAL LOSS OF USE ANAT. LOSS OTHER LOSS
06/14/2025 18 18 24 00 0

VIII.iv.4.A.2.d. Cases Involving Loss of Anal and Bladder Sphincter Control

Under certain circumstances, LOU of both lower extremities, together with loss of anal and bladder sphincter control, satisfies the requirements of 38 CFR 3.350(e)(2) for entitlement to SMC under 38 U.S.C. 1114(o). In such cases, separate ratings for loss of anal and bladder sphincter control are not required. Use SMC basic code 55 to award entitlement.Reference: For more information on adding an SMC code, see the VBMS Rating User Guide.

VIII.iv.4.A.2.e. Avoiding Separate SMC Assignments for L/LOU of an Extremity

Do not assign SMC for

loss or loss of use (L/LOU) of a leg and L/LOU of the foot of the same leg, or
L/LOU of an arm and L/LOU of the hand of the same arm.

If a Veteran has L/LOU of a leg, the L/LOU of the foot of the same leg is subsumed in the level of SMC assigned to the leg. Similarly, if a Veteran has L/LOU of an arm, the L/LOU of the hand of the same arm is subsumed in the level of SMC assigned to the arm. Reference: For more information on avoiding separate assignments for L/LOU of an extremity, see Guillory v. Shinseki, 669 F.3d 1314 (Fed. Cir. 2012).

3. Hospital Adjustments Under 38 CFR 3.552

Introduction

This topic contains information on hospital adjustments under 38 CFR 3.552, including

specifying the basis of entitlement under 38 CFR 3.552 in the rating decision
consequences of an improperly assigned SMC hospital code
example 1 of a rating decision with a properly assigned SMC hospital code, and
example 2 of a rating decision with a properly assigned SMC hospital code.

Change Date

June 16, 2015

VIII.iv.4.A.3.a. Specifying the Basis of Entitlement Under 38 CFR 3.552 in the Rating Decision

The rating decision must specify the basis of the Veteran’s entitlement to a hospital adjustment in order to ensure the proper application of 38 CFR 3.552. The SMC allowance for A&A must be discontinued during hospitalization at government expense, unless the need for A&A is due to

paraplegia involving
- paralysis of both lower extremities, together with
- loss of anal and bladder sphincter control, or
Hansen’s disease.

Exception: The SMC allowance for A&A must be discontinued during hospitalization, regardless of the disability involved, if entitlement is established under

Note: Regardless of pre-existing paraplegia, SMC is payable at the rate prescribed in 38 U.S.C. 1114(n) to a claimant who is entitled to compensation for bilateral disarticulation of the hips under 38 U.S.C. 1151 per VAOPGCPREC 30-1997.References: For more information on entitlement to a higher A&A allowance under
38 U.S.C. 1114(r)(2), see M21-1, Part VIII, Subpart iv, 4.A.9, and
38 U.S.C. 1114(t), see M21-1, Part VIII, Subpart iv, 4.A.11.

VIII.iv.4.A.3.b. Consequences of an Improperly Assigned SMC Hospital Code

The assignment of an improper SMC hospital code may result in erroneous adjustment of the Veteran’s award upon hospitalization.

VIII.iv.4.A.3.c. Example 1: Rating Decision With a Properly Assigned SMC Hospital Code

Situation: The Veteran has
a 100-percent disabling heart condition so severe as to require A&A of another person, and
bilateral, below-knee amputations.
Result: Entitlement under 38 U.S.C. 1114(r)(1) is warranted based upon the need for A&A; entitlement under 38 U.S.C. 1114(l) is also warranted for the bilateral amputations.Coded Conclusion: The proper
SMC basic code is 51, and
SMC hospital code is 19 for SMC under 38 U.S.C. 1114(m).

VIII.iv.4.A.3.d. Example 2: Rating Decision With a Properly Assigned SMC Hospital Code

Situation: The Veteran has a
100-percent disabling psychiatric condition that does not require A&A, and
100-percent disabling heart condition that does require A&A.
Result: Entitlement under 38 U.S.C. 1114(m) is warranted based upon the need for A&A plus an additional 100-percent disability.Coded Conclusion: The proper
SMC basic code is 19, and
SMC hospital code is 48 for SMC under 38 U.S.C. 1114(s).

4. Entitlement to SMC Under 38 U.S.C. 1114(k)

Introduction

This topic contains information on entitlement to SMC under 38 U.S.C. 1114(k), including

criteria for entitlement to SMC under 38 U.S.C. 1114(k)
history of SMC for L/LOU of a creative organ
awarding SMC for L/LOU of a creative organ
basis for considering entitlement to SMC for L/LOU of a creative organ
awarding SMC for LOU of a hand or foot
other medical indications of LOU of the foot, and
awarding SMC for
- LOU of both buttocks
- deafness
- complete organic aphonia
- LOU or blindness of one eye, and
- loss of breast tissue.

Change Date

September 9, 2019

VIII.iv.4.A.4.a. Criteria for Entitlement to SMC Under 38 U.S.C. 1114(k)

SMC under 38 U.S.C. 1114(k) is payable for the following levels of impairment:

L/LOU of a creative organ
L/LOU of a hand
L/LOU of a foot
L/LOU of both buttocks
deafness of both ears having absence of air and bone conduction
complete organic aphonia with constant inability to communicate by speech
blindness in one eye, having light perception only (LPO), and
loss of 25-percent or more of tissue from one or both breasts or breast tissue has been subject to radiation treatment.

VIII.iv.4.A.4.b. History of SMC for L/LOU of a Creative Organ

Public Law (PL) 82-427, which went into effect August 1, 1952, provided for the payment of SMC under 38 U.S.C. 1114(k) for L/LOU of a creative organ. 38 CFR 3.114(a), which provides instructions for assigning effective dates pursuant to liberalizing law or VA policy, became effective December 1, 1962. Accordingly, the proper effective date for awarding entitlement to a Veteran who was otherwise eligible for SMC on August 1, 1952, based on L/LOU of a creative organ, is the earlier of the following two dates, but no earlier than December 1, 1962:
one year before the date VA received the claim, or
one year before the date of an administrative determination of entitlement.
Note: The provisions of 38 CFR 3.114do not apply to female sexual arousal disorder (FSAD). Entitlement to SMC(k) should be established based on the date service connection (SC) for FSAD was established.References: For more information on
the history of SMC under 38 U.S.C. 1114(k), see M21-1, Part VIII, Subpart iv, 4.B.2
SMC and radical prostatectomy, see M21-1, Part V, Subpart iii, 7.3.d
SMC and erectile dysfunction, see
M21-1, Part V, Subpart iii, 7.4.b, and
M21-1, Part VIII, Subpart iv, 4.A.4.d, and
SMC and FSAD, see M21-1, Part V, Subpart iii, 8.A.1.e.

VIII.iv.4.A.4.c. Awarding SMC for L/LOU of a Creative Organ

Award SMC based on L/LOU of a creative organ if medical evidence of record shows

the acquired absence of one or both testicles, ovaries, or other creative organs
a condition of the reproductive tract which results in LOU of a creative organ, such as retrograde ejaculation or spermatozoa dumping into the bladder in a male Veteran
the loss of erectile power secondary to a disease process, such as diabetes or multiple sclerosis, in a male Veteran, or
a diagnosis of FSAD.

Note: SC for prostate cancer does not automatically result in an award of SMC for LOU of a creative organ at the (k) rate unless the prostate cancer was treated by radical prostatectomy.
If the Veteran is SC for prostate cancer and the evidence of record includes a surgical report showing a radical prostatectomy was performed, award SMC (k) effective the date the radical prostatectomy was performed.
If the Veteran is SC for prostate cancer but the evidence of record does not show a radical prostatectomy was performed, clinical evidence of the LOU of a creative organ due to the SC prostate cancer is required to award SMC (k) for LOU of a creative organ due to prostate cancer.
References: For more information on
L/LOU of a creative organ, see
38 CFR 3.350(a)(1)
38 CFR 4.115b, Note, and
38 CFR 4.116, Note 2
erectile dysfunction associated with prostate cancer, see M21-1, Part V, Subpart iii, 7.3.d, and
SMC and FSAD, see M21-1, Part V, Subpart iii, 8.A.1.e.

VIII.iv.4.A.4.d. Basis for Considering Entitlement to SMC for L/LOU of a Creative Organ

The issue of entitlement to SMC for L/LOU of a creative organ may be

based on a specific claim, or
raised within the scope of another claimed issue when entitlement is shown in the evidence of record, such as a VA examination or hospitalization report.

Undertake any development necessary, including submission of a request for a special examination, if there is a reasonable probability of entitlement. Notes:
Entitlement to SMC (k) for one or more creative organs
may be based on a multi-link causal chain between an SC disability and the LOU or anatomical loss, and
is not limited to certain disabilities.
There is no bar to the payment of compensation or establishment of SC for anatomical loss of a creative organ, when a non-service-connected (NSC) LOU of a creative organ existed prior to anatomical loss resulting from service.
The successful use of medication or prosthetic implant to restore erectile ability does not preclude the award of SMC for LOU if the Veteran is unable to complete the act of procreation.
References: For more information on
providing SMC for anatomical loss of a creative organ when a pre-existing NSC functional loss was present, see VAOPGCPREC 5-1989
restoring SMC for anatomical loss of a creative organ when entitlement was originally found to have existed, but was later found not to exist due to suffering a complete loss of procreative power prior to service through surgical removal of certain other organs, see VAOPGCPREC 93-1990, and
considering entitlement to SMC as an ancillary benefit that is within scope of another claimed issue, see
38 CFR 3.155(d)(2)
M21-1, Part V, Subpart ii, 3.A.2.b, and
Payne v. Wilkie, 31 Vet.App. 373 (2019).

VIII.iv.4.A.4.e. Awarding SMC for LOU of a Hand or Foot

Award SMC for LOU of a hand or a foot when function is no better than if the hand or foot were amputated and replaced by prosthesis.When considering LOU, determine whether the following activities could be accomplished equally well by a prosthesis:

grasping or manipulation (for a hand), and
balancing, propulsion, or ambulation (for a foot).

References: For more information on
L/LOU of a hand or foot, see
38 CFR 3.350(a)(2), and
38 CFR 4.63, and
avoiding separate SMC assignments for L/LOU of an extremity, see M21-1, Part VIII, Subpart iv, 4.A.2.e.

VIII.iv.4.A.4.f. Other Medical Indications of LOU of the Foot

Other medical indications of LOU of the foot, as provided in 38 CFR 4.63, include

extremely unfavorable complete ankylosis of the knee
complete ankylosis of two major joints of a lower extremity
shortening of the lower extremity three and one-half inches or more, and
complete paralysis of the external popliteal (common peroneal) nerve and consequent foot drop, accompanied by characteristic organic changes.

VIII.iv.4.A.4.g. Awarding SMC for LOU of Both Buttocks

Award SMC for LOU of both buttocks when there is severe damage by disease or injury to muscle group XVII (the gluteus maximus, gluteus medius, and gluteus minimus), bilaterally, which renders the Veteran unable to complete the following actions without assistance:

rise from a seated or stooped position, and
maintain postural stability.

Note: Assistance performing the physical actions listed above includes the use of the person’s own hands or arms and a special appliance for postural stability.Reference: For more information on LOU of the buttocks, see
38 CFR 3.350(a)(3),and
38 CFR 4.64.

VIII.iv.4.A.4.h. Awarding SMC for Deafness

Award SMC for deafness of both ears, having absence of air and bone conduction, if the SC bilateral hearing loss warrants a 100-percent evaluation under the evaluation criteria in 38 CFR 4.85 and 38 CFR 4.86 for hearing impairment.A Veteran with bilateral SC hearing impairment, numerically designated as XI, is entitled to SMC, regardless of whether or not measurable hearing impairment was noted on entrance into service and SC was awarded based on aggravation of a pre-existing disability.Notes:

A numeric designation of hearing impairment of
- XI in both ears entitles the Veteran to SMC, and
- less than XI in either ear precludes entitlement to SMC.
Base disability ratings only on an examination conducted in a VA-authorized audiology clinic using current testing criteria.
Hearing loss justifying an award of SMC must be permanent in nature.

VIII.iv.4.A.4.i. Awarding SMC for Complete Organic Aphonia

Award SMC for complete organic aphonia if a disability of the organs of speech exists that constantly precludes communication by speech and

the Veteran is unable to communicate by voice or whisper through the normal organs of speech, and
the disability is constant and of organic origin.

Notes:
Complete organic aphonia most frequently results from loss or paralysis of an organ of speech such as the tongue or larynx.
The use of other organs of the body or prosthetic devices to provide voice sounds does not preclude entitlement to SMC.
The assignment of total schedular ratings under 38 CFR 4.97, DCs 6518, 6519, and 6520, and 38 CFR 4.114, DC 7202, generally entitles the Veteran to SMC.

VIII.iv.4.A.4.j. Awarding SMC for LOU or Blindness of One Eye

Award SMC for LOU or blindness of one eye, having LPO, when the Veteran is unable to

recognize test letters at one foot, and
recognize objects, hand movements, or count fingers at a distance of three feet.

Note: SMC is also payable for the anatomical loss of an eye.

VIII.iv.4.A.4.k. Awarding SMC for Loss of Breast Tissue

Entitlement to SMC for loss of tissue from one or both breasts is limited to female Veterans. PL 107-330, enacted December 6, 2002, provides for the payment of SMC
for loss of 25-percent or more of the tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy), or
when breast tissue has been subjected to radiation treatment.
Note: Before enactment of PL 107-330, entitlement to SMC existed only upon complete surgical removal of breast tissue (or the equivalent loss of breast tissue due to injury), which included radical mastectomy, modified radical mastectomy, and simple (or total) mastectomy.Reference: For more information on entitlement to SMC for loss of breast tissue, see 38 CFR 4.116.

5. SMC for Blindness With Other Disabilities Affecting Hearing and the Extremities

Introduction

This topic contains information on SMC for blindness with other disabilities affecting hearing and the extremities, including

basic criteria for entitlement to
- SMC (l), and
- SMC (m)
general criteria for entitlement to SMC for blindness with hearing loss or L/LOU of an extremity
SMC for
- bilateral deafness evaluated as 60 percent or more and bilateral visual acuity of 20/200 or less, and
- total SC deafness in one ear and bilateral blindness
example 1 of a rating decision involving SMC for total SC deafness in one ear and bilateral blindness
example 2 of a rating decision involving SMC for total SC deafness in one ear and bilateral blindness
SMC for bilateral blindness with bilateral hearing loss considered 10- or 20-percent disabling
example 1 of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 10- or 20-percent disabling
example 2 of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 10- or 20-percent disabling
SMC for bilateral blindness with bilateral hearing loss considered 30-percent disabling
an example of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 30-percent disabling
SMC for bilateral blindness with bilateral hearing loss considered 40-percent disabling
example 1 of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 40-percent disabling
example 2 of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 40-percent disabling
SMC for bilateral blindness with bilateral hearing loss considered 60-percent disabling
an example of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 60-percent disabling
SMC for bilateral blindness with L/LOU of an extremity considered at least 50-percent disabling
an example of a rating decision involving SMC for bilateral blindness with L/LOU of an extremity considered at least 50-percent disabling
SMC for bilateral blindness with L/LOU of a lower extremity considered less than 50-percent disabling, and
an example of a rating decision involving SMC for bilateral blindness with L/LOU of a lower extremity considered less than 50-percent disabling.

Change Date

June 23, 2025

VIII.iv.4.A.5.a. Basic Criteria for Entitlement to SMC (l)

The SMC rate payable under 38 U.S.C. 1114(l) is authorized for the following as a result of SC disability:

anatomical L/LOU of both feet
anatomical L/LOU of one hand and one foot
blindness in both eyes with visual acuity of 5/200 or less
being permanently bedridden, or
being so helpless as to be in need of the regular A&A of another person.

VIII.iv.4.A.5.b. Basic Criteria for Entitlement to SMC (m)

The SMC rate payable under 38 U.S.C. 1114(m) is authorized for the following as a result of SC disability:

anatomical L/LOU of both hands
anatomical L/LOU of both legs at a level, or with complications, preventing natural knee action with prostheses in place
anatomical L/LOU of one arm and one leg preventing natural elbow and knee action with prostheses in place, due to the level of involvement or with complications
blindness in both eyes having LPO, or
blindness in both eyes leaving the Veteran so significantly disabled as to be in need of regular A&A.

VIII.iv.4.A.5.c. General Criteria for Entitlement to SMC for Blindness With Hearing Loss or L/LOU of an Extremity

Additional SMC is payable to Veterans with bilateral blindness who are already entitled to SMC under 38 U.S.C. 1114(l) through (n) who also have varying degrees of SC hearing loss or SC L/LOU of an extremity.

VIII.iv.4.A.5.d. SMC for Bilateral Deafness Evaluated as 60 Percent or More and Bilateral Visual Acuity of 20/200 or Less

A Veteran is entitled to SMC under 38 U.S.C. 1114(o) if the Veteran has a combination of

bilateral deafness rated at 60 percent or more (and the hearing loss in either ear is SC), and
SC blindness with bilateral visual acuity of 20/200 (6/60) or less.

Note: Before the enactment of PL 110-157 on December 26, 2007, SC blindness with bilateral visual acuity of 5/200 (1.5/60) or less was required for entitlement to SMC under 38 U.S.C. 1114(o).

VIII.iv.4.A.5.e. SMC for Total SC Deafness in One Ear and Bilateral Blindness

A Veteran with total SC deafness in one ear, such as that numerically designated as “XI,” and SC blindness with

LPO or less, bilaterally, is entitled to SMC under 38 U.S.C. 1114(o) and 38 CFR 3.350(e)(1)(iv), or
visual acuity of 5/200 (1.5/60) or less, bilaterally, is entitled to an additional half step in the level of SMC, under the provisions of 38 CFR 3.350(f)(2)(iv).

VIII.iv.4.A.5.f. Example 1: Rating Decision Involving SMC for Total SC Deafness in One Ear and Bilateral Blindness

Situation: The Veteran has
bilateral SC blindness with LPO
total SC hearing loss in the left ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.
Result: Since the Veteran has LPO bilaterally and total SC loss of hearing in the left ear, entitlement to SMC is warranted under
38 U.S.C. 1114(o), and
38 CFR 3.350(e)(1)(iv).
Coded Conclusion:
The appropriate SMC paragraph code is OB-2.
The appropriate SMC coding is 37-37-21-00-0.

VIII.iv.4.A.5.g. Example 2: Rating Decision Involving SMC for Total SC Deafness in One Ear and Bilateral Blindness

Situation: The Veteran has
bilateral SC blindness with
no light perception (NLP) in the left eye, and
visual acuity of 5/200 (1.5/60) in the right eye
total SC hearing loss in the left ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.
Result: The Veteran is entitled to SMC under 38 U.S.C. 1114(m) for the degree of bilateral blindness alone, but an additional half step in the level of SMC (“m½”) is warranted, based on the degree of hearing loss, under the provisions of 38 CFR 3.350(f)(2)(iv).Coded Conclusion:
The appropriate SMC paragraph code is PB-1.
The appropriate SMC coding is 20-20-21-00-0.

VIII.iv.4.A.5.h. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10- or 20-Percent Disabling

A Veteran is entitled to an additional half step in the level of SMC under 38 CFR 3.350(f)(2)(v) if the disabilities include

SC bilateral blindness with LPO or less, and
bilateral hearing loss, considered 10- or 20-percent disabling (and the hearing loss is SC in at least one ear).

Note: If visual acuity in either of the eyes is better than LPO, entitlement to the additional half step does not exist.

VIII.iv.4.A.5.i. Example 1: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10- or 20-Percent Disabling

Situation: The Veteran has

anatomical loss of the left eye
LPO in the right eye
SC bilateral hearing loss, evaluated as 20-percent disabling
no total hearing loss in either ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.

Result: The appropriate level of SMC for the degree of blindness alone is “m½.” However, an additional half step is warranted based on the degree of hearing loss, making the Veteran entitled to SMC under 38 U.S.C. 1114(n). Coded Conclusion:

The appropriate SMC paragraph code is PB-2.
The appropriate SMC coding is 21-21-11-11-0.

VIII.iv.4.A.5.j. Example 2: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10- or 20-Percent Disabling

Situation: The Veteran has

anatomical loss of the left eye
visual acuity of 5/200 (1.5/60) in the right eye
SC bilateral hearing loss, evaluated as 20-percent disabling
no total hearing loss in either ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.

Result: Since visual acuity in the right eye is better than LPO, do not apply 38 CFR 3.350(f)(2)(v). The Veteran is entitled to SMC under 38 U.S.C. 1114(m).Coded Conclusion:

The appropriate SMC paragraph code is MB-2.
The appropriate SMC coding is 19-19-11-11-0.

VIII.iv.4.A.5.k. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 30-Percent Disabling

A Veteran is entitled to an additional full step in the level of SMC, not to exceed that provided by 38 U.S.C. 1114(o) and 38 CFR 3.350(f)(2)(vi), if the disabilities include

SC visual acuity of 5/200 (1.5/60) or less, bilaterally, and
bilateral hearing loss, considered at least 30-percent disabling (and the hearing loss is SC in at least one ear).

VIII.iv.4.A.5.l. Example: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 30-Percent Disabling

Situation: The Veteran has

anatomical loss of the left eye
visual acuity of 5/200 (1.5/60) in the right eye
SC bilateral hearing loss evaluated as 30-percent disabling
no total hearing loss in either ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.

Result: The Veteran is entitled to SMC under the provisions of 38 U.S.C. 1114(m) for the degree of blindness alone. However, an additional full step is warranted under the provisions of 38 CFR 3.350(f)(2)(vi), thereby entitling the Veteran to SMC under 38 U.S.C. 1114(n). Coded Conclusion:

The appropriate SMC paragraph code is PB-3.
The appropriate SMC coding is 21-21-11-11-0.

VIII.iv.4.A.5.m. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 40-Percent Disabling

A Veteran is entitled to SMC under 38 U.S.C. 1114(o) and 38 CFR 3.350(e)(1)(iv) if the disabilities include

SC blindness with LPO or less in both eyes, and
either
- bilateral hearing loss, considered at least 40-percent disabling (and the hearing loss is SC in at least one ear), or
- SC total hearing loss in one ear.

Note: If bilateral blindness is present, but visual acuity in either eye is better than LPO, the Veteran is entitled to an additional full step only in the level of SMC, not to exceed that provided by 38 U.S.C. 1114(o), per 38 CFR 3.350(f)(2)(vi).

VIII.iv.4.A.5.n. Example 1: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 40-Percent Disabling

Situation: The Veteran has

NLP in the right eye
LPO in the left eye
SC bilateral hearing loss evaluated as 40-percent disabling
no total hearing loss in either ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.

Result: The appropriate level of SMC for the degree of bilateral blindness alone is “m ½.” However, apply 38 CFR 3.350(e)(1)(iv) because of the coexisting hearing loss. The Veteran is accordingly entitled to SMC under 38 U.S.C. 1114(o). Coded Conclusion:

The appropriate SMC paragraph code is OB-2.
The appropriate SMC coding is 37-37-21-00-0.

VIII.iv.4.A.5.o. Example 2: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 40-Percent Disabling

Situation: The Veteran has

NLP in the right eye
visual acuity of 5/200 (1.5/60) in the left eye
SC bilateral hearing loss, evaluated as 40-percent disabling
no total hearing loss in either ear
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.

Result: The Veteran is entitled to SMC under 38 U.S.C. 1114(m) for the degree of bilateral blindness alone. However, because of the degree of hearing loss present, increase the level of SMC by a full step under the provisions of 38 CFR 3.350(f)(2)(vi) and award SMC under 38 U.S.C. 1114(n). Coded Conclusion:

The appropriate SMC paragraph code is PB-3.
The appropriate SMC coding is 21-21-21-00-0.

VIII.iv.4.A.5.p. SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 60-Percent Disabling

A Veteran is entitled to SMC under 38 U.S.C. 1114(o) and 38 CFR 3.350(e)(1)(iii) if the disabilities include

SC visual acuity of 20/200 (6/60) or less, bilaterally, and
bilateral hearing loss, considered at least 60-percent disabling (and the hearing loss is SC in at least one ear).

VIII.iv.4.A.5.q. Example: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 60-Percent Disabling

Situation: The Veteran has

LPO in the right eye
visual acuity of 20/200 (6/60) in the left eye
SC bilateral hearing loss, evaluated as 60-percent disabling
no total hearing loss in either ear
no separate and distinct disability evaluated as 100-percent disabling
no separate and distinct disability evaluated as 50-percent disabling, and
no entitlement to A&A.

Result: Due to the coexisting blindness and hearing loss, the Veteran is entitled to SMC under 38 U.S.C. 1114(o) and 38 CFR 3.350(e)(1)(iii).Coded Conclusion:

The appropriate SMC paragraph code is OB-1.
The appropriate SMC coding is 37-37-21-00-0.

VIII.iv.4.A.5.r. SMC for Bilateral Blindness With L/LOU of an Extremity Considered at Least 50-Percent Disabling

The provisions of 38 CFR 3.350(f)(2)(vii)(A) and 38 CFR 3.350(f)(2)(vii)(B) allow for an additional full step of SMC, not to exceed entitlement under 38 U.S.C. 1114(o), if the Veteran has

visual acuity of 5/200 (1.5/60) or less, bilaterally, and
SC L/LOU of an upper or lower extremity, which by itself or in combination with another compensable disability is considered at least 50-percent disabling.

Note: Payment of this additional full step of SMC is in addition to the SMC payable under 38 CFR 3.350(a).

VIII.iv.4.A.5.s. Example: Rating Decision Involving SMC for Bilateral Blindness With L/LOU of an Extremity Considered at Least 50-Percent Disabling

Situation: The Veteran has

SC bilateral blindness with visual acuity of 5/200 (1.5/60)
SC LOU of the dominant hand evaluated as 50-percent disabling
no separate and distinct disability evaluated as 100-percent disabling, and
no separate and distinct disability evaluated as 50-percent disabling.

Result: The Veteran is entitled to SMC under 38 U.S.C. 1114(l) for the degree of blindness alone. The Veteran is also entitled to an additional full step of SMC, plus SMC under 38 CFR 3.350(a), for LOU of the right hand. Accordingly, the appropriate level of SMC is “m+k.” Coded Conclusion:

The appropriate SMC paragraph code is PB-4.
The appropriate SMC coding is 25-25-35-00-0.

VIII.iv.4.A.5.t. SMC for Bilateral Blindness With L/LOU of a Lower Extremity Considered Less Than 50-Percent Disabling

A Veteran is entitled to an additional half step of SMC under 38 CFR 3.350(f)(2)(vii)(C) if the SC disabilities include

visual acuity of 5/200 (1.5/60) or less, bilaterally
L/LOU of a foot, considered less than 50-percent disabling, and
no other compensable SC disability.

Note: The level of SMC may not exceed that provided by 38 U.S.C. 1114(o).

VIII.iv.4.A.5.u. Example: Rating Decision Involving SMC for Bilateral Blindness With L/LOU of a Lower Extremity Considered Less Than 50-Percent Disabling

Situation: The Veteran has

visual acuity of 5/200 (1.5/60), bilaterally
a below-the-knee amputation of the right foot evaluated as 40-percent disabling, and
no other compensable disabilities.

Result: The Veteran is entitled to SMC under 38 U.S.C. 1114(l) based on the degree of blindness alone. The Veteran is also entitled to SMC under 38 U.S.C. 1114(k) for loss of the right foot. The appropriate level of SMC, therefore, is “l+k.” Award an additional half step of SMC (l½ +k) under the provisions of 38 CFR 3.350(f)(2)(vii)(C).Coded Conclusion:

The appropriate SMC paragraph code is PB-6.
The appropriate SMC coding is 24-24-21-13-0.

Note: The SMC Calculator will ask whether the Veteran was on active duty after September 11, 2001. Answering Yes to that question prompts additional questions regarding the Veteran’s ability to ambulate with and without the use of ambulation aides. Answering No to the question of whether the Veteran was on active duty after September 11, 2001, does not prompt any additional questions. Depending on the answers provided to the additional prompts, the resulting SMC paragraph code and coding may differ from the example provided.

6. SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)

Introduction

This topic contains information on SMC for additional 50- and 100-percent evaluations under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4),including

proper application of 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)
SMC under
- 38 CFR 3.350(f)(3), and
- 38 CFR 3.350(f)(4)
permanence requirement for SMC under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4), and
an example of a rating decision involving SMC under
- 38 CFR 3.350(f)(3), and
- 38 CFR 3.350(f)(4).

Change Date

March 23, 2026

VIII.iv.4.A.6.a. Proper Application of 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)

Apply the provisions of 38 CFR 3.350(f)(3) or 38 CFR 3.350(f)(4), whichever is appropriate, only once in a rating decision. Important: Concurrent entitlement to SMC under both 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4) is prohibited.

VIII.iv.4.A.6.b. SMC Under 38 CFR 3.350(f)(3)

A Veteran entitled to SMC under 38 U.S.C. 1114(l) through (n) is entitled to the next higher intermediate rate of SMC under the provisions of 38 CFR 3.350(f)(3) if the SC disabilities include an additional single permanent disability, or a combination of disabilities, that is independently evaluated as 50-percent or more disabling.

VIII.iv.4.A.6.c. SMC Under 38 CFR 3.350(f)(4)

A Veteran who is entitled to SMC under 38 U.S.C. 1114(l) through (n) is entitled to the next higher statutory rate of SMC under the provisions of 38 CFR 3.350(f)(4) if the SC disabilities include an additional single permanent disability that is independently evaluated as 100-percent disabling, apart from any consideration of individual unemployability (IU).Note: Per Bradley v. Peake, 22 Vet.App. 280 (2008), do not define “single disability” in accordance with 38 CFR 4.16, as this regulation applies only to total disability based on IU.

VIII.iv.4.A.6.d. Permanence Requirement for SMC Under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)

Disability evaluations used to support entitlement under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4) must be permanent with no future review examination scheduled.

VIII.iv.4.A.6.e. Example: Rating Decision Involving SMC Under 38 CFR 3.350(f)(3)

Situation: The Veteran has SC disabilities as shown below and qualifies for
SMC under 38 U.S.C. 1114(m) on account of the anatomical loss of both hands, and
two disabilities (blindness of one eye, having LPO, and loss of a creative organ) that each qualify for SMC under 38 U.S.C. 1114(k).
Result: As provided in 38 CFR 3.350(f)(3), in addition to and independent of the disability for which SMC is payable under 38 U.S.C. 1114(m), the following permanent disabilities exist that are independently ratable as 50-percent disabling:
blindness of the right eye, having LPO, evaluated as 30-percent disabling, and
loss of both testes, evaluated as 30-percent disabling.
Accordingly, the requirements of 38 CFR 3.350(f)(3) are met for the rate intermediate between 38 U.S.C. 1114(m) and 38 U.S.C. 1114(n), plus rates under 38 U.S.C. 1114(k). Coded Conclusion:SUBJECT TO COMPENSATION (1. SC)
5106 AMPUTATION, BOTH HANDS AT WRIST
100 percent from 02/01/2026.6064 BLINDNESS, RIGHT EYE, LIGHT PERCEPTION ONLY; LEFT EYE 20/20
30 percent from 02/01/2026.7524 REMOVAL OF BOTH TESTES
30 percent from 02/01/2026.COMBINED EVALUATION FOR COMPENSATION:
100 percent from 02/01/2026.SPECIAL MONTHLY COMPENSATIONK-1 Entitled to SMC under 38 U.S.C. 1114(k) and 38 CFR 3.350(a) on account of blindness of one eye, having light perception only, from 02/01/2026.K-1 Entitled to SMC under 38 U.S.C. 1114(k) and 38 CFR 3.350(a) on account of anatomical loss of a creative organ from 02/01/2026.M-1 Entitled to SMC under 38 U.S.C. 1114(m) and 38 CFR 3.350(c) on account of anatomical loss of both hands from 02/01/2026.P-1 Entitled to SMC under 38 U.S.C. 1114(p) and 38 CFR 3.350(f)(3) at the rate intermediate between 38 U.S.C. 1114(m) and 38 U.S.C. 1114(n) on account of anatomical loss of both hands with additional disabilities of blindness of the right eye, having light perception only, and removal of both testes, independently ratable as 50-percent disabling or more from 02/01/2026.The appropriate SMC coding is shown in the table below.
EFFECTIVE DATE BASIC HOSPITAL LOSS OF USE ANAT. LOSS OTHER LOSS
02/01/2026 31 31 11 23 1

VIII.iv.4.A.6.f. Example: Rating Decision Involving SMC Under 38 CFR 3.350(f)(4)

Situation: The Veteran has anatomical loss of both lower extremities that meets the requirements for SMC under 38 U.S.C. 1114(m) and a 100 percent SC evaluation for posttraumatic stress disorder (PTSD) that is completely independent of the anatomical loss of both lower extremities.Result: As provided in 38 CFR 3.350(f)(4), the Veteran is entitled to the next higher rate of SMC, 38 U.S.C. 1114(n), because of the additional, single, permanent disability that is independently ratable as 100-percent disabling.Coded Conclusion:
SUBJECT TO COMPENSATION (1. SC)5107 ANATOMICAL LOSS OF BOTH LOWER EXTREMITIES ABOVE THE KNEES
100 percent from 12/01/2025.9411 POSTTRAUMATIC STRESS DISORDER
100 percent from 12/01/2025.COMBINED EVALUATION FOR COMPENSATION:
100 percent from 12/01/2025.SPECIAL MONTHLY COMPENSATIONM-2 Entitled to SMC under 38 U.S.C. 1114(m) and 38 CFR 3.350(c) from 12/01/2025 on account of anatomical loss of one leg at a level or with complications preventing natural knee action with prosthesis in place, and loss of use of the other leg at a level with complications preventing natural knee action with prosthesis in place.P-2 Entitled to SMC under 38 U.S.C. 1114(p) and 38 CFR 3.350(f)(4) equal to 38 U.S.C. 1114(n) from 12/01/2025 on account of entitlement to SMC under 38 U.S.C. 1114(m) with additional disability, posttraumatic stress disorder, independently ratable as 100-percent disabling.The appropriate SMC coding is shown in the table below.
EFFECTIVE DATE BASIC HOSPITAL LOSS OF USE ANAT. LOSS OTHER LOSS
12/01/2025 21 21 00 24 0

7. Entitlement to Additional SMC for L/LOU of Three Extremities Under 38 CFR 3.350(f)(5)

Introduction

This topic contains information on additional SMC for L/LOU of three extremities under 38 CFR 3.350(f)(5), including

considering L/LOU of three extremities, and
an example of a rating decision involving additional SMC for L/LOU of three extremities.

Change Date

September 29, 2006

VIII.iv.4.A.7.a. Considering L/LOU of Three Extremities

A Veteran with L/LOU of three extremities is entitled to additional SMC under 38 CFR 3.350(f)(5).To determine the correct rate of SMC payable to a Veteran with the requisite degree of disability,

decide the rate of SMC payable without regard to 38 CFR 3.350(f)(5), and
increase this rate to the next higher rate authorized under 38 U.S.C. 1114(l) through (n), without loss of any entitlement under 38 U.S.C. 1114(k).

Notes:

The term “next higher rate” is intended to include the intermediate rates authorized under 38 U.S.C. 1114(p).
The total monthly amount payable (minus any additional amount for dependents) must not exceed the amount stated in 38 U.S.C. 1114(p).

VIII.iv.4.A.7.b. Example: Rating Decision Involving Additional SMC for L/LOU of Three Extremities

Situation: The Veteran has the SC disabilities shown below and qualifies for SMC under 38 U.S.C. 1114(m) on account of the anatomical loss of both hands. Entitlement to SMC under 38 U.S.C. 1114(k) for an amputation of the left foot also exists. In addition, the Veteran is entitled to an additional half step in the level of SMC, under 38 CFR 3.350(f)(3), due to the separate disabilities ratable as 50-percent or more disabling.Result: The rate of SMC payable without regard to 38 CFR 3.350(f)(5) is “m½ +k.” Elevate this rate to the next higher rate authorized under 38 U.S.C. 1114(l) through (n), without loss of entitlement under 38 U.S.C. 1114(k). Accordingly, the rate of SMC payable in this case is “n+k.”Coded Conclusion:SUBJECT TO COMPENSATION (1. SC)5106 AMPUTATION, BOTH HANDS AT WRIST
100 percent from 06/01/2025.5165 AMPUTATION, LEFT FOOT, BELOW KNEE
40 percent from 06/01/2025.7101 HYPERTENSION
20 percent from 06/01/2025.COMBINED EVALUATION FOR COMPENSATION:100 percent from 06/01/2025.SPECIAL MONTHLY COMPENSATIONK-1 Entitled to SMC under 38 U.S.C. 1114(k) and 38 CFR 3.350(a) on account of anatomical loss of one foot from 06/01/2025.M-1 Entitled to SMC under 38 U.S.C. 1114(m) and 38 CFR 3.350(c) on account of anatomical loss of both hands from 06/01/2025.P-1 Entitled to SMC under 38 U.S.C. 1114(p) and 38 CFR 3.350(f)(3) at the rate intermediate between 38 U.S.C. 1114(m) and 38 U.S.C. 1114(n) on account of anatomical loss of both hands with additional disabilities of amputation of the left foot and hypertension independently ratable as 50-percent or more disabling from 06/01/2025.P-3 Entitled to SMC under 38 U.S.C. 1114(p) and 38 CFR 3.350(f)(5) at the next higher rate or intermediate rate of 38 U.S.C. 1114(n) due to loss of three extremities from 06/01/2025.The appropriate SMC coding is shown in the table below.
EFFECTIVE DATE BASIC HOSPITAL LOSS OF USE ANAT. LOSS OTHER LOSS
06/01/2025 27 27 00 32 0

8. Entitlement to SMC Based on the Need for A&A

Introduction

This topic contains information on entitlement to SMC based on a demonstrated need for the A&A of another person, including

criteria for entitlement to A&A under 38 CFR 3.352(a)
considering
- the level of disability required for entitlement to A&A
- entitlement to A&A when the evaluation for a single disability is less than 100 percent
- permanence when evaluating claims for A&A
- entitlement to A&A as an inferred issue, and
importance of reasoning in awarding SMC under 38 U.S.C 1114(l) when considering entitlement to A&A under 38 U.S.C. 1114(o)
coding the rating decision to reflect entitlement to A&A or housebound
denying entitlement to A&A
entitlement to A&A under the provisions of PL 96-128, and
drafting and coding the rating decision awarding entitlement to A&A under PL 96-128.

Change Date

June 23, 2025

VIII.iv.4.A.8.a. Criteria for Entitlement to A&A Under 38 CFR 3.352(a)

The criteria for entitlement to A&A, which appear in 38 CFR 3.352(a), mandate that the Veteran be so helpless due to physical or mental incapacity as a result of SC disability requiring the aid of another person to perform the personal functions required in everyday living.References: For more information on

considering permanence in A&A determinations, see M21-1, Part VIII, Subpart iv, 4.A.8.d, and
entitlement to special monthly spouse’s compensation based on a spouse’s need for A&A, see M21-1, Part VIII, Subpart iv, 4.A.12.

VIII.iv.4.A.8.b. Considering the Level of Disability Required for Entitlement to A&A

A single disability evaluated as 100-percent disabling under a schedular evaluation is generally a prerequisite for entitlement to A&A. There is not a statutory or regulatory requirement for a 100-percent disability to qualify for A&A. However, any lesser disability would typically be incompatible with the requirements of 38 CFR 3.352(a).Explanation: Both the nature of the impairment (being in need of regular A&A) and the compensation indicate that a greater level of disability is required for entitlement to the additional allowance for A&A than for
entitlement to SMC at the housebound rate, or
a 100-percent schedular evaluation.
Important:
The single disability rated as totally disabling must be the sole or partial cause of the need for A&A.
38 CFR 4.16 applies only to IU determinations. It does not permit decision makers to apply 38 CFR 4.16 guidelines on what constitutes a single disability to A&A determinations.
Temporary 100-percent evaluations under 38 CFR 4.28, 4.29, and 4.30 qualify for the single schedular evaluation needed for entitlement to A&A. However, grants of entitlement to A&A are not routine in these circumstances.
To establish entitlement to SMC (t), the need for A&Amust be due to traumatic brain injury (TBI) or multiple disabilities due to TBI that combine to a 100-percent evaluation.
Exception: Claims processed under the relaxed standard per the October 2014 Veterans Service Center Manager Bulletin (from October 16, 2014, through December 18, 2015) will not be affected.Note: The following fact patterns represent a “single disability” for purposes of establishing entitlement to SMC (l):
Evaluations of facets or multisystem effects of a single disease entity (including, but not limited to, multiple sclerosis, Parkinson’s disease, or diabetes mellitus) combine to 100 percent without regard to other conditions and A&A is required as a result of SC disability. Multisystem diseases are rated under a primary DC or by separate ratings of residuals under multiple DCs when more advantageous to the claimant.
Evaluations of primary and secondary SC disabilities combine to 100 percent and A&A is required as a result of SC disability.
Example 1: A Veteran is SC for Parkinson’s disease and has multiple disabilities related to the disease that result in a combined 100-percent schedular evaluation. If the evidence shows that the disabilities related to Parkinson’s disease are so severe that the Veteran requires A&A, entitlement to SMC (l) must be awarded.Example 2: A Veteran is SC for amputation of the right leg at the hip at 90-percent disabling. Pursuant to 38 CFR 3.310(c), SC is subsequently established for ischemic heart disease secondary to the right leg amputation evaluated as 60-percent disabling. If the evidence shows the Veteran requires A&A due to the heart condition and right leg amputation, entitlement to SMC (l) is warranted.References: For more information on considering entitlement to SMC based on the need for A&A
when the schedular rating is less than 100 percent, see M21-1, Part VIII, Subpart iv, 4.A.8.c, and
for residuals of TBI, see
38 CFR 3.350(j), and
M21-1, Part VIII, Subpart iv, 4.A.11.

VIII.iv.4.A.8.c. Considering Entitlement to A&A When the Evaluation for a Single Disability Is Less Than 100 Percent

Use the table below when

entitlement to A&A is at issue, and
a Veteran’s evaluation for a single disability is less than 100 percent.

Important: The evidence in the case must include the report from a current examination or its equivalent.

If the Veteran does not have …	And …	Then …
a single disability evaluated as 100-percent disabling, but the combined disability evaluation is 100 percent (based on the disease processes noted in M21-1, Part VIII, Subpart iv, 4.A.8.b)	the disability is so severe as to demonstrate a need for A&A	award A&A.
a single disability evaluated as 100 percent (regardless of the combination)	the disability is so severe as to demonstrate the need for A&A	refer the case to Compensation Service for an advisory opinion requesting consideration for entitlement to A&A on an extra-schedular basis.Reference: For more information on requesting an advisory opinion, see M21-1, Part X, Subpart v, 1.A.2.
a single disability evaluated as 100 percent (regardless of the combination)	the disability does not demonstrate a need for A&A	dispose of the issue by explaining how this conclusion was reached in the Narrative of the rating decision.
a single disability evaluated as 100 percent (regardless of the combination)	the disability does not demonstrate a need for A&A, but evidence shows that the disability has worsened	order an examination or render a decision for increased evaluation based on the evidence of record if adequate for rating purposes.

VIII.iv.4.A.8.d. Considering Permanence When Evaluating Claims for A&A

Entitlement to SMC as discussed in 38 CFR 3.352(a) may be established based on the need for the regular A&A of another person without regard to whether such need is permanent. Reference: For more information on considering permanence when evaluating A&A, see VAOPGCPREC 21-1994.

VIII.iv.4.A.8.e. Considering Entitlement to A&A as an Inferred Issue

If a single disability is evaluated as 100-percent disabling, consider entitlement to A&A or the housebound rate as an inferred issue only if the evidence shows that the benefit may be awarded. If the evidence does not show entitlement to SMC at the A&A or housebound rate, do not raise either issue merely to deny it.

VIII.iv.4.A.8.f. Importance of Reasoning in Awarding SMC Under 38 U.S.C 1114(l) When Considering Entitlement to A&A Under 38 U.S.C. 1114(o)

Make determinations of entitlement to SMC under 38 U.S.C. 1114(l) on the basis of need for regular A&A in light of the criteria contained in 38 CFR 3.352(a). Fully explain the reasoning in the Narrative of the rating decision. Notes:

The need to explain the reasoning is especially important in situations in which, under 38 CFR 3.350(e), the rate under 38 U.S.C. 1114(l) based on the need for A&A is to be used as one of the conditions that entitles the claimant to two or more of the rates (no condition being considered twice) that are provided in 38 U.S.C. 1114(l) through (n) for the purpose of establishing entitlement under 38 U.S.C. 1114(o).
Base the determination of need for A&A on separate and distinct disabilities if the rate under 38 U.S.C. 1114(l) on account of need for A&A is used to establish entitlement under 38 U.S.C. 1114(o).

Example: If a Veteran has LOU of both feet and is also being considered for the maximum rate under 38 U.S.C. 1114(o) because of the need for A&A, the need for A&A must be due to SC disabilities completely independent of the LOU of both feet. When determining whether the Veteran needs A&A, disregard the disabling effects of the LOU of both feet. Show the need for A&A as due to a separate SC disability evaluated as 100-percent disabling.

VIII.iv.4.A.8.g. Coding the Rating Decision to Reflect Entitlement to A&A or Housebound

Show entitlement to SMC, based on the need for A&A or evidence showing the Veteran is housebound, by

using the appropriate SMC paragraph(s) on the Codesheet, immediately following statement of the combined degree of disability, and
entering the necessary SMC codes in the data table.

Reference: For more information on proper SMC coding to ensure the Veteran’s rate is correctly adjusted during hospitalization, see M21-1, Part X, Subpart iii, 1.C.1.f.

VIII.iv.4.A.8.h. Denying Entitlement to A&A

If the Veteran or representative specifically claimed entitlement to A&A but the evidence does not support an award of A&A, dispose of the issue by explaining the reasons and bases of the decision to deny A&A in the Narrative of the rating decision.Notes:
When A&A and/or housebound are not specifically claimed, do not infer entitlement to A&A or housebound SMC rates to deny the benefit(s).
When VA Form 21-2680is received, follow the procedures at M21-1, Part II, Subpart iii, 1.A.3.a to determine which issues must be addressed in a rating.
If evidence indicates that an SC disability, which is alleged or reasonably raised as a contributing factor to A&A, has worsened, do not deny A&A before a decision is rendered concerning the evaluation for the SC disability.

VIII.iv.4.A.8.i. Entitlement to A&A Under the Provisions of PL 96-128

PL 96-128 amended 38 U.S.C. 1114(r) concerning the awarding of A&A in cases where the SMC level is “n½ +k,” so that the SC disabilities used to establish entitlement to SMC at this level may also be used to establish entitlement to A&A if factual need is shown.Under PL 96-128, entitlement to SMC under
38 U.S.C. 1114(r)(1) exists if the basic criteria contained in 38 CFR 3.352(a) are met, and
38 U.S.C. 1114(r)(2) exists if the basic criteria contained in 38 CFR 3.352(b) are met.
Note: Prior to enactment of PL 96-128, a Veteran had to be entitled to SMC under 38 U.S.C. 1114(o) in order to establish entitlement to SMC under 38 U.S.C. 1114(r)(1) and 38 U.S.C. 1114(r)(2).

VIII.iv.4.A.8.j. Drafting and Coding the Rating Decision Awarding Entitlement to A&A Under PL 96-128

If entitlement to A&A is established under the provisions of PL 96-128, then
cite relevant evidence and information in the Narrative to fully justify awarding or denying A&A, and
use SMC code 43 or 44, whichever is applicable.
Note: Pay the rate allowed for SMC at the “n½ +k” level, plus the additional amount allowed under 38 U.S.C. 1114(r)(1) or 38 U.S.C. 1114(r)(2), whichever is appropriate.Reference: For more information on entitlement to a higher A&A allowance under 38 U.S.C. 1114(r)(2), see M21-1, Part VIII, Subpart iv, 4.A.9.

9. Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

Introduction

This topic contains information on the statutory provisions for a higher A&A allowance, including

entitlement to a higher A&A allowance under 38 U.S.C. 1114(r)(2)
when to award a higher A&A allowance under 38 U.S.C. 1114(r)(2)
evidentiary considerations for higher level of care
processing claims for entitlement to a higher A&A allowance under 38 U.S.C. 1114(r)(2),and
possible hospitalization adjustment under 38 CFR 3.552(b)(2).

Change Date

October 27, 2016

VIII.iv.4.A.9.a. Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

A Veteran entitled to the A&A allowance under 38 U.S.C. 1114(r)(1) is entitled to receive, in lieu of that allowance, a higher A&A allowance under 38 U.S.C 1114(r)(2) if the Veteran is found to be in need of, and receiving, a higher level of care.

VIII.iv.4.A.9.b. When to Award a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

Award the higher A&A allowance under 38 U.S.C. 1114(r)(2)only when the

need is clearly established, and
the amount of skilled services required by the Veteran is substantial.

Base entitlement to the higher allowance on medical certification that the Veteran meets the criteria set forth in 38 CFR 3.352(b).Note: Entitlement to the higher A&A allowance may be awarded when an otherwise eligible Veteran is receiving residential or nursing home care in an institution at the Veteran’s own expense. If such skilled care is provided at VA expense, this award may be subject to reduction under 38 CFR 3.552(b)(2).Reference: For more information on entitlement to a higher A&A allowance when the Veteran is receiving residential or nursing home care in an institution, see

VAOPGCPREC 23-1992, and
M21-1, Part VIII, Subpart iv, 4.A.9.e.

VIII.iv.4.A.9.c. Evidentiary Considerations for Higher Level of Care

To establish entitlement to a higher A&A allowance under 38 U.S.C 1114(r)(2), the evidence of record must indicate

an ongoing need for skilled personal care, and
in the absence of such care, the Veteran would require hospitalization, nursing home care, or other residential institutional care.

Note: Entitlement may be established by evidence which shows the
conditions justifying the need for this level of care
nature, extent, and frequency of the services provided, and
nature and extent of the supervision being provided, if the services are actually provided by a non-professional.

VIII.iv.4.A.9.d. Processing Claims for Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

Follow the steps in the table below to process claims for entitlement to a higher A&A allowance under 38 U.S.C. 1114(r)(2).

Step

Action

Does the claim include evidence showing that the Veteran

requires ongoing daily skilled care, and
in the absence of such care, would require hospitalization, nursing home care, or other residential institutional care?

If yes, award entitlement to the higher A&A allowance under 38 U.S.C. 1114(r)(2).
If no, go to Step 2.

Perform any necessary development, including requesting an examination.Important: If an examination is necessary, the request should ask the examiner to state whether the Veteran

requires ongoing daily skilled personal care, and
in the absence of such care, would require hospitalization, nursing home care, or other residential institutional care.

Note: PL 103-446 removed the requirement for VA examination when private evidence is adequate to evaluate any claim for benefits administered under Chapter 11 of 38 U.S.C., which includes entitlement under 38 U.S.C. 1114. This PL was implemented by regulatory change revising 38 CFR 3.352(b) on August 25, 1995, to remove the requirement for VA examination to evaluate claims for entitlement to SMC (r)(2). PL 103-446 and the resulting implementing regulatory change supersede the language still included at 38 U.S.C. 1114(r)(2) that indicates VA examination is required.

Does the evidence of record, including any examination report(s), show an ongoing need for skilled personal care and, in the absence of such care, the Veteran would require hospitalization, nursing home care, or other residential institutional care?

If yes, award entitlement to the higher A&A allowance under 38 U.S.C. 1114(r)(2).
If no, prepare a rating decision denying the claim.

VIII.iv.4.A.9.e. Possible Hospitalization Adjustment Under 38 CFR 3.552(b)(2)

The A&A allowance, including that payable under 38 U.S.C. 1114(r)(2), is subject to possible hospitalization adjustment, or reduction, under 38 CFR 3.552(b)(2).

10. Entitlement to Housebound Benefits

Introduction

This topic contains information about entitlement to housebound benefits, including

statutory entitlement to housebound benefits
defining a single disability for housebound purposes
extra-schedular consideration on housebound claims involving IU
temporary total ratings used to award SMC (s)
determining whether the Veteran is
- permanently housebound in fact, and
- substantially confined for housebound-in-fact entitlement, and
protected evaluations in determination of housebound entitlement.

Change Date

June 23, 2025

VIII.iv.4.A.10.a. Statutory Entitlement to Housebound Benefits

The housebound benefit, or SMC (s), is payable under 38 U.S.C. 1114(s) and 38 CFR 3.350(i) to a Veteran who has a single, SC disability evaluated as totally disabling, and

has an additional SC disability, or combination of disabilities, independently evaluated as 60-percent or more disabling, or
is permanently housebound due to SC disability.

If the Veteran is entitled to housebound benefits by statute (without demonstrating need, under 38 U.S.C. 1114(s)), the additional disability(ies), evaluated as 60-percent or more disabling, must

be separate and distinct from the single disability evaluated as totally disabling, and
involve separate anatomical segments or body systems.

Notes:

The principles regarding avoidance of pyramiding contained in 38 CFR 4.14 are applicable.
Within these limits, the fact that the single disability evaluated as totally disabling and additional disability(ies), independently evaluated as 60-percent or more disabling, share a common etiology does not preclude entitlement.
In determining entitlement for SMC benefits pursuant to 38 U.S.C. 1114(s), an erroneous disability evaluation that is protected by the 20-year rule under 38 CFR 3.951(b) must be used in calculating the total percentage of disability to establish entitlement, as indicated in VAOPGCPREC 16-1989.

VIII.iv.4.A.10.b. Defining a Single Disability for Housebound Purposes

A single disability evaluated as 100-percent disabling under a schedular evaluation is generally a prerequisite for entitlement to housebound benefits. Exception: A total disability evaluation based on IU, which is in turn awarded based on one disability, satisfies the regulatory requirement of “a single SC disability rated as 100 percent” for the purpose of awarding SMC housebound benefits under 38 CFR 3.350(i). Important:

The VA Office of General Counsel concluded in VAOPGCPREC 66-1991 that, based on the specific statutory and regulatory language used in 38 U.S.C. 1114(s) and 38 CFR 3.350(i), there must be one single disability rated at 100-percent disabling to establish entitlement at the SMC (s) rate. Multiple disabilities that combine to 100 percent, even if from a common etiology, do not satisfy the requirement for “a single SC disability rated as 100 percent” for the purpose of SMC housebound benefits.
A total rating based on IU when awarded for multiple disorders treated as one disability under the five options listed in 38 CFR 4.16(a)does not satisfy the regulatory requirement under 38 CFR 3.350(i) of “a single SC disability rated as 100 percent.”
The Court of Appeals for Veterans Claims (CAVC) noted in Bradley v. Peake, 22 Vet.App. 280 (2008), that restrictive language precluding an IU evaluation from satisfying the “total” requirement of 38 U.S.C. 1114(s) was dropped from the implementing regulation, 38 CFR 3.350(i), in 1995 following VAOPGCPREC 2-1994 that held that 38 U.S.C. 1114 did not authorize such a restriction.
- CAVC only clarified in the Bradley decision that there was no restriction under 38 U.S.C. 1114(s) preventing the consideration of a “total” evaluation based on an SC disability used for IU.
- If IU was granted based on a single disability and the Veteran has additional disabilities combining to 60 percent, SMC (s) can be granted prior to November 26, 2008, the date of the Bradley holding.
- Follow the procedures at M21-1, Part V, Subpart ii, 4.A.7.a to determine the proper effective date for entitlement to SMC based on the Bradley holding.

Example – IU award based on a single disability: A Veteran is in receipt of IU based solely on depression evaluated as 70-percent disabling. Subsequently, SC is granted for coronary artery disease (CAD) and a 60-percent evaluation is assigned. SMC (s) at the statutory housebound rate is awarded. Analysis: The Veteran in this instance would be entitled to the statutory SMC housebound rate. Under Bradley, awarding IU based on the single disability of depression satisfies the requirement for a single disability evaluated as totally disabling for the purpose of SMC (s) entitlement. CAD is an additional disability evaluated as at least 60-percent disabling and is separate and distinct from the SC depression and associated IU. Example – IU award based on multiple disabilities: A Veteran is in receipt of IU based on two SC disabilities: ankylosis of the right shoulder evaluated as 50-percent disabling and residuals of a left radius fracture evaluated as 20-percent disabling. Both disabilities are due to a motor vehicle accident (MVA) that happened during the Veteran’s active-duty service. Entitlement to IU was awarded based on the disabilities caused by the MVA. The Veteran’s separate issue of CAD is later granted SC and evaluated as 60-percent disabling. The CAD, by itself, does not render the Veteran unemployable. SMC (s) at the statutory housebound rate is not awarded. Analysis: The Veteran in this instance would not be entitled to SMC at the statutory housebound rate. There is no single disability evaluated as totally disabling for the purpose of entitlement to SMC. Although the evaluations for the MVA injuries to the shoulder and left radius are considered to be a single disability for the purpose of IU entitlement, they do not represent a single disability evaluated at 100-percent disabling for the purpose of awarding SMC at the statutory housebound rate. Reference: For more information on the single 100-percent disability requirement for SMC (s), see
Bradley v. Peake, 22 Vet.App. 280 (2008)
Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011)
Youngblood v. Wilkie, 31 Vet.App. 412 (2019), and
VAOPGCPREC 66-1991.

VIII.iv.4.A.10.c. Extra-Schedular Consideration in Housebound Claims Involving IU

When SMC at the statutory housebound rate is established based on a single condition that is totally disabling due to IU

the single disability must meet the schedular criteria for entitlement to IU defined in 38 CFR 4.16(a) without regard to the other SC disabilities, or
an extra-schedular determination under 38 CFR 4.16(b) must be made with a finding that the single disability is so disabling as to result in IU.

When the evidence of record establishes potential entitlement to SMC at the statutory housebound rate due to a single disability resulting in IU status but the disability does not, by itself, meet the schedular criteria to establish IU entitlement, forward the case to Compensation Service for an extra-schedular IU determination as directed in 38 CFR 4.16(b) for the purpose of deciding entitlement to SMC at the statutory housebound rate. Example: A Veteran is SC for migraine headaches evaluated as 50-percent disabling and for multiple orthopedic conditions that combine for an additional 60-percent evaluation. The evidence shows that the migraine headaches prevent gainful employment. Although the criteria to grant entitlement to IU have been met as there are multiple disabilities that combine to 70 percent with one that is at least 40-percent disabling, entitlement to SMC based on statutory housebound status requires an extra-schedular determination since the headaches, by themselves, do not meet the schedular criteria for the grant of IU. References: For more information on

defining a single disability for the purpose of establishing entitlement to housebound benefits, see M21-1, Part VIII, Subpart iv, 4.A.10.b
evaluating claims for entitlement to a total disability evaluation based on IU, see M21-1, Part VIII, Subpart iv, 3.B and C, and
requests for extra-schedular determinations, see M21-1, Part V, Subpart ii, 3.D.3.

VIII.iv.4.A.10.d. Temporary Total Ratings Used to Award SMC (s)

Temporary evaluations of 100 percent under 38 CFR 4.28, 38 CFR 4.29, and 38 CFR 4.30 of the rating schedule may be used as a basis for awarding SMC at the housebound rate. Example: A Veteran with an SC knee disability is awarded a temporary total evaluation under 38 CFR 4.30 for two months following surgery. The Veteran is SC for PTSD, which is rated 70-percent disabling. SMC (s) will also be awarded while the total rating under 38 CFR 4.30 is in effect, as the separate PTSD evaluation of 70 percent establishes the basis for award of SMC at the housebound rate.

VIII.iv.4.A.10.e. Determining Whether the Veteran Is Permanently Housebound in Fact

If entitlement is based on the Veteran being housebound in fact, the law requires the housebound state to be permanent.Consider a Veteran permanently housebound under 38 CFR 3.350(i)(2) if, as a result of a single total disability, by itself or in combination with other SC disabilities, the Veteran is permanently and substantially confined to the

place of residence and immediate premises, or
ward or clinical areas, if institutionalized.

Important: There is no requirement that either the single disability evaluated as totally disabling or the additional disability(ies), independently ratable as 60-percent or more disabling, be permanent in nature if SMC at the housebound rate is awarded on a statutory, rather than factual, basis. Reference: For more information on substantial confinement to the home, see Howell v. Nicholson, 19 Vet.App. 535 (2006).

VIII.iv.4.A.10.f. Determining Whether the Veteran Is Substantially Confined for Housebound-in-Fact Entitlement

A housebound-in-fact determination requires a Veteran’s inability to leave the place of residence and immediate premises in order to earn any income. However, it does not require a total inability to leave the place of residence and immediate premises for all circumstances. Leaving home for medical purposes cannot, by itself, serve as the basis for finding that a Veteran is not substantially confined for the purpose of SMC housebound benefits. The limitations must be the result of the Veteran’s SC disabilities. Non-medical indicators of housebound status may include but are not limited to

inability to walk substantial distances
leaving the home with assistance only occasionally for
- appointments
- grocery shopping, or
- church, or
inability to mow one’s lawn.

Example 1: A Veteran is totally disabled due to SC diabetes mellitus and related complications. He leaves his house weekly for dialysis treatment. His SC conditions limit his ability to independently ambulate to less than 30 feet before requiring significant rest. The Veteran is entitled to SMC based on housebound-in-fact status as his inability to leave the home other than for medical visits demonstrates substantial confinement to the place of residence and immediate premises. Furthermore, the diabetes mellitus and complications are so disabling that he is rendered unable to leave his residence and immediate premises to earn income.Example 2: A Veteran is SC for multiple disabilities including CAD, which is totally disabling. His wife drives him to all medical appointments. If the Veteran experiences a good day, they may run some minor errands while out of the home. The Veteran is entitled to SMC based on housebound-in-fact status as leaving his home for medical visits does not preclude a finding of substantial confinement to his dwelling or immediate premises. Furthermore, the other outings where the Veteran’s activity is limited to minor errands does not preclude a finding of substantial confinement since the Veteran is not shown to be able to leave his place of residence and immediate premises in order to earn income. Reference: For more information on determining whether a Veteran is substantially confined for the purpose of housebound determinations, see

Howell v. Nicholson, 19 Vet.App. 535 (2006), and
Hartness v. Nicholson, 20 Vet.App. 216 (2006).

VIII.iv.4.A.10.g. Protected Evaluations in Determination of Housebound Entitlement

Consider any evaluation protected under 38 CFR 3.951 at its protected level. For the purpose of determining entitlement to housebound benefits only, utilize ratings under the 1925 schedule, which are protected by 38 CFR 3.952, with ratings under the current rating schedule for separate and distinct disabilities.Reference: For more information on determining entitlement to SMC based on protected evaluations, see M21-1, Part X, Subpart ii, 1.B.1.h.

11. Entitlement to SMC Under 38 U.S.C. 1114(t) Based on the Need for A&A for Residuals of TBI

Introduction

This topic contains information about entitlement to SMC (t) based on the need for A&A for residuals of TBI, including

criteria for entitlement to SMC (t)
developing for SMC (t), and
determining SMC codes and paragraphs for SMC (t).

Change Date

January 5, 2026

VIII.iv.4.A.11.a. Criteria for Entitlement to SMC (t)

PL 111-275 amended 38 U.S.C. 1114 effective October 1, 2011, to authorize payment of SMC (t), which is equal to the rate payable for SMC (r)(2), for Veterans who
need regular A&A for SC residuals of TBI, but
are not eligible for SMC under (r)(2), and
would require hospitalization, nursing home care, or other residential institutional care in the absence of regular A&A.
Notes:
SMC (t) authorized by PL 111-275 is not the same historical SMC (t) rate that was discontinued in 1986. The current benefit cannot be awarded or rated using that historical code.
38 CFR 3.350(j), 38 CFR 3.352(b)(2), and 38 CFR 3.552(b)(2) were updated to implement PL 111-275 on June 7, 2018.
In Laska v. McDonough, 37 Vet.App. 460 (2024), CAVC held that 38 CFR 3.352(b)(2) is invalid. This regulation required that a Veteran show the need for a higher level of care to qualify for SMC (t). However, CAVC found in Laska that this regulation was stricter than the authorizing statute under 38 U.S.C. 1114(t), which requires a need for regular A&A for SC residuals of TBI, without which the Veteran would require hospitalization, nursing home care, or other residential institutional care. Thus, CAVC held that a higher level of care is not necessary to qualify under 38 U.S.C. 1114(t).
Important: If the Veteran is in need of regular A&A for SC residuals of TBI and does not meet criteria for SMC (r)(2), but the evidence does not show that the Veteran would require hospitalization, nursing home care, or other residential institutional care in the absence of regular A&A, then an award of SMC (t) is not warranted. In such a case, award SMC (l) based on the need for A&A due to TBI, if otherwise in order. References: For more information on
evaluating TBI, see M21-1, Part V, Subpart iii, 12.B, and
awards of SMC (l) for A&A, see M21-1, Part VIII, Subpart iv, 4.A.8.

VIII.iv.4.A.11.b. Developing for SMC (t)

General development rules apply to claims for SMC (t). If a VA medical examination, opinion, or both are required, request a TBI examination.Important: If an examination is necessary, the request should ask the examiner to state whether the Veteran would require hospitalization, nursing home care, or other residential institutional care in the absence of regular A&A for residuals of TBI.Use the table below to determine the type of VA examination to request when entitlement to SMC for TBI is at issue.
If SC has ...
Then ...
not been established for residuals of TBI, and a TBI exam is needed
order an initial TBI exam using the Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI)Disability Benefits QuestionnaireandVA Form 21-2680.
already been established for residuals of TBI, anda TBI exam is needed
order a TBI review exam using the Review Evaluation of Residuals of Traumatic Brain Injury(R-TBI) Disability Benefits QuestionnaireandVA Form 21-2680.

VIII.iv.4.A.11.c. Determining SMC Codes and Paragraphs for SMC (t)

Use the table below to determine the proper SMC codes and paragraph(s) to input into VBMS-R when granting entitlement to SMC (t).

If the Veteran is entitled to ...

Then ...

SMC (t) only with no other SMC entitlement, or
SMC (t) and other SMC entitlement(s) less than SMC (l), such as SMC (k)

enter the applicable effective date(s) for all SMC entitlement(s), and any other necessary information, into the SMC calculator, and
use the generated SMC codes and paragraph(s) to input the SMC entitlement(s) into VBMS-R.

Example: When SMC (t) is the only SMC entitlement, the appropriate

SMC paragraph is T-2, and
SMC coding is 61-48-00-00-4.

SMC (t), and
other SMC entitlement equal to or higher than SMC (l), in addition to and based on separate disabilities than the SMC (t)

enter the applicable effective dates for all SMC entitlements, and any other necessary information, into the SMC calculator, and
use the generated SMC codes and paragraphs to input the SMC entitlements into VBMS-R, with the following exceptions:
- if the SMC calculator generates a basic code corresponding to SMC (r)(2) entitlement, use the SMC basic code of 61 instead, and
- if the SMC calculator generates an R-2 SMC paragraph, enter the T-2 SMC paragraph into VBMS-R instead.
Note: These instructions are an exception to the general requirement to use the results provided by the SMC calculator. The changes described above are necessary to properly document SMC (t) entitlement in these particular scenarios. Decision makers should use the generated SMC calculator results except for an SMC basic code or paragraph that improperly denotes SMC (r)(2) entitlement, because one of the criteria for SMC (t) is that the Veteran does not meet the requirements for SMC (r)(2).

Important: Reduction for hospitalization will be made to the rate equal to SMC (s) in cases where there is no underlying SMC entitlement other than to A&A for TBI residuals. Otherwise, the hospitalization rate will be paid according to underlying SMC entitlement for all qualifying disabilities. References: For more information on

the criteria for entitlement to SMC (t), see
- M21-1, Part VIII, Subpart iv, 4.A.11.a
- 38 U.S.C. 1114(t), and
- Laska v. McDonough, 37 Vet.App. 460 (2024)
entering SMC decisions into VBMS-R, see the VBMS Rating User Guide, and
reduction of SMC during hospitalization, see 38 CFR 3.552.

12. Entitlement to Special Monthly Spouse’s Compensation

Introduction

This topic contains information about entitlement to additional compensation based on the need for A&A for a Veteran’s spouse, including

spousal A&A criteria, and
requirement for a 30-percent rating.

Change Date

September 9, 2019

VIII.iv.4.A.12.a. Spousal A&A Criteria

Increased compensation is payable to a Veteran by reason of the Veteran’s spouse being in need of A&A. The spouse will be considered in need of A&A if the individual

is blind with corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less
is a patient in a nursing home because of mental or physical incapacity, or
has disabilities causing a factual need for A&A as defined in 38 CFR 3.352(a).

Note: Special monthly spouse’s compensation may be granted by the authorization activity when the spouse’s nursing home status is confirmed, as discussed at 38 CFR 3.351(c)(2) and M21-1, Part VI, Subpart i, 1.A.3.b. References: For more information on
special monthly spouse’s compensation, see 38 CFR 3.351
effective dates for special monthly spouse’s compensation, see
38 CFR 3.401(a)(3), and
M21-1, Part V, Subpart ii, 4.A.5.g
reviewing VA Form 21-2680 for claims for spousal A&A, see M21-1, Part II, Subpart iii, 1.A.3.b
requesting examinations for non-Veteran claimants and beneficiaries, see M21-1, Part IV, Subpart i, 2.E.2.a, and
entitlement to special monthly pension, Dependency and Indemnity Compensation, or death compensation based on the need for A&A of a surviving spouse, see M21-1, Part IX, Subpart ii, 1.A.1.d.

VIII.iv.4.A.12.b. Requirement for a 30-Percent Rating

For additional benefits to be payable for a spouse, including for special monthly spouse’s compensation ratings, the Veteran must be entitled to compensation for disabilities evaluated as 30-percent or more disabling.Reference: For more information on handling claims for additional compensation for dependents from Veterans with a combined disability rating that is less than 30 percent, see M21-1, Part VII, Subpart i, 1.A.4.c.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part VIII, Subpart iv, Chapter 4, Section A (U.S. government work, reproduced for reference). Browse all sections →