38 CFR Part 4 — 38 CFR § 4.88
Chronic Fatigue Syndrome Cfs
dc-6354-chronic-fatigue-syndrome-cfs
Infectious / immune
Diagnostic code
6354
Why your DC matters: DC 6354 is the exact code the VA uses to rate this condition. It determines which symptoms unlock which percentage, what evidence the rater looks for, and which secondaries are most likely to be approved.
Last verified against 38 CFR (eCFR Part 4):
Rating criteria (38 CFR Part 4)
Diagnostic code 6354 — Chronic Fatigue Syndrome Cfs — is listed under 38 CFR § 4.88 in 38 CFR Part 4. The paragraphs below summarize how this code is used; the official schedule text controls exact percentages, formulas, and notes.
Schedule summary (educational, not a substitute for the regulation): Educational index row from the rating schedule naming convention; confirm exact diagnostic code, effective date, and criteria in the current eCFR Part 4.
Exact rating criteria: Open Part 4 in the eCFR (link under “Official source” below). Locate your diagnostic code number (6354) in the correct body-system subpart, or use Find in Page (Ctrl+F / ⌘F) for “6354”. Copy the verbatim rating table, including any parenthetical notes, exceptions, and cross-references, for the version of Part 4 that applies to your effective date.
Effective dates & which schedule version applies
Which diagnostic code, percentage, and effective date apply depends on the facts of your claim and the version of the rating schedule in force for the period being decided. Generally, VA applies the schedule in effect at the specified time under 38 U.S.C. § 5110 and implementing rules, subject to exceptions (e.g., protected ratings, liberalizing law changes—see regulation and VA manual policy as applicable).
For older claims, the **current** eCFR may not match the text that applied years ago. If your decision references a prior percentage or code, compare against the Part 4 text **as of** your claim’s relevant dates; historical Federal Register / CFR snapshots may be needed for precise comparison.
The “Last verified” date on this page is when we last checked this educational summary against the electronic CFR—not the date of any VA policy or your personal claim decision.
Notes for your claim
Evidence: Show that your diagnosis and severity match the factors the schedule names for DC 6354 (e.g., measurements, frequency, treatment, functional loss), with medical and lay evidence as appropriate.
C&P exams: Results should reflect the schedule’s requirements (correct joints measured, correct formulas). If the exam omits required findings, consider submitting records or requesting clarification.
If you disagree with the DC, percentage, or effective date, review the Part 4 text for your period and consider a supplemental claim or appeal with a VA-accredited representative.
This site does not provide legal advice.
Official source
38 CFR Part 4 (eCFR) — locate diagnostic code 6354 in the subpart for your body system (use Find in Page if needed).
Chronic fatigue syndrome under DC 6354 has an unusual rating scheme tied to symptom impact on activity level. Gulf War veterans get presumptive service connection under 38 CFR § 3.317 — same as fibromyalgia and IBS. The tier-driver is what percentage of pre-illness activity level the veteran can maintain, with periods of incapacitation as a parallel path. Veterans rated 10% for 'fatigue symptoms' often qualify for 40%-60% once activity reduction is properly documented.
Rating Tiers — What Each Percentage Requires
| Rating | What It Takes | Evidence That Supports It |
|---|---|---|
| 100% | Symptoms which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. | Functional assessment documenting near-total restriction of routine activities; ADL impairment notes; provider statements noting episodic inability to perform self-care. |
| 60% | Symptoms which are nearly constant and restrict routine daily activities to less than 50% of the pre-illness level; OR symptoms which wax and wane, resulting in periods of incapacitation of at least 6 weeks total duration per year. | Activity log showing <50% of pre-illness level; documented incapacitation episodes totaling 6+ weeks/year; provider's functional assessment. |
| 40% | Symptoms which are nearly constant and restrict routine daily activities to 50-75% of the pre-illness level; OR symptoms which wax and wane, resulting in periods of incapacitation of at least 4 but less than 6 weeks total duration per year. | Activity log + functional assessment + chart notes documenting flare/recovery cycles. |
| 20% | Symptoms which are nearly constant and restrict routine daily activities by less than 25% of the pre-illness level; OR symptoms which wax and wane, resulting in periods of incapacitation of at least 2 but less than 4 weeks total duration per year. | Provider note documenting persistent symptoms + ADL impact; weeks-of-incapacitation diary. |
| 10% | Debilitating fatigue, cognitive impairments, or a combination of other signs and symptoms which wax and wane but result in periods of incapacitation of at least 1 but less than 2 weeks total duration per year; OR symptoms controlled by continuous medication. | Diagnosis + treatment record + brief incapacitation history. |
What Qualifies Under DC 6354?
Diagnosis using recognized CFS/ME criteria
CDC Fukuda criteria, IOM/NAM 2015 criteria (now used for SEID — Systemic Exertion Intolerance Disease), International Consensus Criteria. Generic 'chronic fatigue' doesn't qualify.
Activity-level + incapacitation drive tier
DC 6354 schedule (per current § 4.88b):
- • 10% — Wax/wane 1-2 wks/yr incapacitation OR symptoms controlled by continuous Rx
- • 20% — Nearly constant + <25% restriction OR wax/wane 2-4 wks/yr incapacitation
- • 40% — Nearly constant + 50-75% restriction OR wax/wane 4-6 wks/yr incapacitation
- • 60% — Nearly constant + <50% of pre-illness activity OR wax/wane 6+ wks/yr incapacitation
- • 100% — Nearly constant + so severe as to restrict almost completely + may occasionally preclude self-care
Gulf War presumptive available
Per § 3.317, CFS in SW Asia veterans (Aug 2, 1990-present) is presumed service-connected.
Language Your Rater Needs to See
These are the exact (or near-exact) regulatory phrases that unlock specific tiers. If your DBQ or C&P report doesn't use this vocabulary, the rater may default to a lower percentage even when symptoms qualify.
“Nearly constant + so severe as to restrict routine daily activities almost completely + may occasionally preclude self-care”
100% gate is qualitatively higher than 60% — almost complete restriction PLUS occasional self-care preclusion. Both elements must be in the chart. The '<50% pre-illness level' criterion lives at 60%, not 100%.
“Less than 50% of pre-illness activity level OR ≥6 weeks/year incapacitation”
60% gate. Compare to pre-illness baseline — work, exercise, social activities, household tasks. Provider should chart explicit comparison. Alternatively, sum incapacitation weeks per year.
“Periods of incapacitation totaling X weeks per year”
Cumulative weeks of incapacitation are the wax/wane path on every tier (10%/20%/40%/60%). 'Incapacitation' = bedridden or unable to perform routine activities. Track and sum.
“Post-exertional malaise (PEM)”
Hallmark of CFS — symptoms worsen 24-72 hours after physical or mental exertion. Newer IOM/NAM criteria require PEM for diagnosis. Document explicitly.
Evidence Checklist — Specific to This Condition
Diagnosis by qualified provider using current criteria (CDC, IOM/NAM, ICC)
CRITICALMust use a recognized CFS/ME diagnostic criteria set. Generic 'fatigue' diagnoses don't anchor DC 6354.
Activity log comparing pre- vs. post-illness baseline
CRITICALDrives every tier. Hours of productive activity, work capacity, exercise tolerance, social activities — before vs. after.
Incapacitation diary
CRITICALNumber of bedridden / unable-to-function days/weeks per year. Drives higher tiers.
Gulf War service records (if applicable)
IMPORTANTDD-214 showing SW Asia service Aug 2, 1990 — present. Triggers § 3.317 presumptive.
Workup ruling out other causes
IMPORTANTSleep study (excludes OSA), thyroid panel, B12, depression screen, autoimmune panel. CFS is partially diagnosis of exclusion.
C&P Exam Tips
Bring a written activity comparison — before vs. now
Specific examples: 'I used to run 5K three times a week. Now I can walk 200 yards before needing to rest.'
Document post-exertional malaise explicitly
'After my daughter's birthday party, I was bedridden for 3 days.' PEM is the modern hallmark of CFS diagnosis.
Bring incapacitation diary
Days/weeks/year of being unable to function. Drives the higher tiers.
Don't minimize cognitive symptoms ('brain fog')
CFS cognitive impairment is real and rateable. Describe specific examples — forgetting words, losing track mid-sentence, inability to focus on reading.
Common Mistakes That Cost Veterans Points
Filing as 'chronic fatigue' or 'tiredness'
Generic terms don't anchor DC 6354. Need formal 'chronic fatigue syndrome' or 'myalgic encephalomyelitis' diagnosis.
Skipping Gulf War presumptive path
Same as fibromyalgia — SW Asia service Aug 1990-present triggers § 3.317 presumptive. No nexus letter required.
Not documenting pre-illness baseline
Tier comparison requires before/after. Without a clear pre-illness activity baseline, examiners default to lower tiers.
Tactical Plays
⚡ Gulf War presumptive — file even with no in-service onset proof
Per § 3.317, CFS in a Persian Gulf veteran is presumed service-connected. DD-214 + current diagnosis = grant. Same path as fibromyalgia and IBS.
⚡ Stack with fibromyalgia and IBS
All three are Gulf War presumptive and frequently comorbid. Each rates separately under its own DC. Many veterans claim only one, missing 2 ratings entirely.
⚡ Document post-exertional malaise (PEM) carefully
PEM is the IOM/NAM-criteria hallmark. Even if the original diagnosis is older, getting a current provider to chart PEM strengthens the diagnostic foundation.
Secondary Conditions to File With This One
Major depressive disorder
STRONGDC 9434
Chronic CFS drives depression; well-documented secondary pathway.
Fibromyalgia
STRONGDC 5025
Highly comorbid with CFS; both are Gulf War presumptive. Rate each separately.
IBS
MODERATEDC 7319
Functional GI commonly accompanies CFS; third Gulf War presumptive condition.
Sleep disorder (non-restorative sleep)
MODERATENon-restorative sleep is a CFS hallmark; if formal diagnosis (e.g., insomnia, sleep-wake disorder), rate separately.
Compensation Scenarios
2026 rates (effective Dec 1, 2025, per va.gov)
10% — single, no dependents
Base rating
$180.42
TOTAL
$180.42/mo
Wax/wane 1-2 wks/yr incapacitation OR symptoms controlled by continuous Rx.
20% — single, no dependents
Base rating
$356.66
TOTAL
$356.66/mo
Nearly constant + <25% restriction OR wax/wane 2-4 wks/yr incapacitation.
40% — single, no dependents
Base rating
$795.84
TOTAL
$795.84/mo
Nearly constant + 50-75% restriction OR wax/wane 4-6 wks/yr incapacitation.
60% — single, no dependents
Base rating
$1,435.02
TOTAL
$1,435.02/mo
Nearly constant + <50% of pre-illness activity OR wax/wane 6+ wks/yr incapacitation.
100% — single, no dependents
Base rating
$3,938.58
TOTAL
$3,938.58/mo
Nearly constant + restricts daily activities almost completely + may occasionally preclude self-care.
60% CFS + 40% fibromyalgia + 30% IBS (Gulf War stack)
Base rating
$2,362.30
TOTAL
$2,362.30/mo
Combined ~83% rounds to 80-90% depending on order — three Gulf War presumptives stacked.
Note: Amounts are approximations rounded to nearest dollar. Actual comp varies with effective date, dependents (spouse, children, parents — each adds), Aid & Attendance, and additional disabilities. Combined ratings use VA Math (§ 4.25), not simple addition.
Key Definitions
💥What is Post-Exertional Malaise (PEM)?
Worsening of CFS symptoms 24-72 hours after physical, mental, or emotional exertion. Hallmark of IOM/NAM and current diagnostic criteria. The 'crash' phenomenon.
📊What's 'Pre-illness Activity Level'?
The veteran's functional baseline before CFS onset — work capacity, exercise, social engagement, household tasks. Used as comparison anchor for tier determination.
🪖What's the Gulf War presumptive?
38 CFR § 3.317 presumes service connection for CFS (and fibromyalgia, IBS) in veterans who served in SW Asia from Aug 2, 1990 onward, regardless of in-service symptom documentation.
How to File Your Claim
Get a formal CFS/ME diagnosis from qualified provider
Internist, rheumatologist, or specialist using CDC/IOM/NAM criteria.
Build activity diary + pre-illness baseline comparison
Hours of productive activity, work capacity, exercise tolerance, social engagement — before vs. now.
Document incapacitation in weeks/year
Drives higher tiers. Bedridden days, missed work weeks, periods of being unable to function.
File 21-526EZ specifying 'chronic fatigue syndrome (DC 6354)'
If Gulf War service applies, ALSO write 'presumptive service connection under 38 CFR § 3.317.'
Stack fibromyalgia + IBS + MDD secondaries if applicable
All four can rate independently for Gulf War veterans.
Typical Claim Timeline
File initial claim
Day 0–7: Submit VA Form 21-526EZ with all medical evidence on file
VA acknowledges claim
Week 1–2: Receive confirmation letter and claim tracking number
C&P examination scheduled
Month 1–3: VA contracts an exam vendor and sends you appointment notice
Attend C&P exam
Bring your full evidence package; describe symptoms on your worst days, not your best
Decision & rating notice
Month 3–6: Decision letter with rating percentage and effective date
First payment & retro back pay
Within 15 days of decision; retroactive to claim date (or effective date if earlier)
Timeline varies by case complexity and VA regional office workload. Some claims resolve faster; others take longer.
Important Considerations
Gulf War service = presumptive
DD-214 showing SW Asia service Aug 2, 1990-present triggers § 3.317. No nexus letter required.
Stack with fibromyalgia + IBS
All three Gulf War presumptives — file each separately. Most veterans claim only one.
Activity-level comparison drives tier
Without a pre-illness baseline + current activity log, examiners default to low tiers.
Document PEM explicitly
Post-exertional malaise is the modern diagnostic hallmark — strengthens the foundation of any rating claim.
Related Tools & Resources
Frequently Asked Questions
Is CFS always presumptive for Gulf War veterans?
Yes — per § 3.317, CFS is one of three 'medically unexplained chronic multisymptom illnesses' presumed service-connected for veterans who served in SW Asia from Aug 2, 1990 to the present (fibromyalgia and IBS are the other two).
Can I get a rating if my diagnosis is 'ME' instead of 'CFS'?
Yes — myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS) are typically used interchangeably. DC 6354 covers both. IOM/NAM 2015 criteria use 'SEID' (Systemic Exertion Intolerance Disease) — also covered.
What if my CFS is caused by long COVID?
Long-COVID-associated CFS is rateable under DC 6354 with proper documentation. SC pathway depends on whether the COVID infection was service-connected — pursue presumptive paths if applicable to your service period.
Does TDIU apply to CFS?
Frequently yes — CFS severe enough to restrict pre-illness activity to <50% almost by definition prevents substantial gainful employment. Combined with secondaries (fibro, IBS, MDD), TDIU eligibility is common.
Official Regulatory Source
Chronic fatigue syndrome is rated under 38 CFR § 4.88b, DC 6354. Gulf War presumptive at § 3.317.
38 CFR § 4.88b — Infectious Diseases, Immune Disorders (eCFR) →Scroll to DC 6354.
Next Steps
If your rating decision lists DC 6354, compare your current symptoms and documentation against the criteria above. Consider:
- Requesting a copy of your rating decision and C&P exam report from the VA
- Gathering all relevant medical records (VA and private providers)
- Documenting functional limitations and how they impact work and daily activities
- Obtaining a nexus letter if needed to establish or strengthen service connection
- Filing for secondary conditions that may be related to this primary condition
- Contacting a VA-accredited VSO, claims agent, or attorney to review your file
This is general educational information only — not legal or medical advice.
Also: DC code lookup (tools) lists the same index in a compact layout.
Source: 38 CFR Part 4, Diagnostic Code 6354 • va.gov
⚠️ Important Disclaimer
This page provides general educational information only based on public VA regulations (38 CFR) and va.gov resources. It is not legal, medical, or claims assistance. Ratings and service connections are decided case-by-case by the VA based on the individual veteran’s evidence. We do not prepare claims, generate documents, or provide personalized advice. Always consult a VA-accredited Veterans Service Organization (VSO), attorney, or your physician for help with your specific situation. Verify the latest rules on va.gov.