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C&p Exam For Tmj

Question

Anyone have any recent experience with the VA performing a C&P TMJ exam?

Will the comprehensive exam performed by a VA Oral Surgeon count the same as a C&P exam?

I am looking to file an increase from 10% to a higher percentage because my ROM has deteriorated significantly. I am hoping they can use my most recent examination instead of putting me to the meat grinder again.

On 12/24/2009, the VA oral surgeon gave me an examination for my TMJ pain. The "completed care:" indicated (D0150) COMPREHENSIVE ORAL EVALUATION. The exam took almost an hour and included a new panorex x-ray. I looked up the VA Dental and Oral C&P exam, but it was lacking in specific details (see below). The doc put me on a soft/no-chew diet for six weeks and gave me anti-inflammatory and muscle relaxer meds.

Here is a snippet of some of the highlights from the Oral Surgery examination:

TMJ

Pt only opened to 18 mm but no findings

PAIN

TMJ: Bilateral

Temporalis: Bilateral

Medial Pterygoid: Bilateral

Lateral Pterygoid: Bilateral

Posterior Neck: Bilateral

MIO: 18 mm

MIO (without pain): 10 mm

Right lateral excursion: 0 mm

Left lateral excursion: 3 mm

Protrusive: 1 mm

Deviation on opening: 0 mm

Incisal display (at rest): 3 mm

OB (mm): 0 mm

OJ (mm): 0 mm

Insisial display (smile): 6 mm

Maxillary midline: 0 mm

Mandibular Midline: 3 mm

ASSESSMENT

TMJ exacerbation s/p increased clenching and reported incident of being struck with xray machine boon on chin.

Here is a link the Dental and Oral C&P exam

http://www.vba.va.gov/bln/21/Benefits/exams/disexm12.htm

Here is the text of the exam, which is rather brief.

Dental and Oral Examination

Dental and Oral Syndrome

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: Regional Office action is required for all dental treatment based on combat wounds, service trauma, prisoner of war or extracted teeth under 38 CFR 17.123.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

Address each of the following and fully describe:

1. Describe extent of functional impairment due to loss of motion and masticatory function loss.

2. Describe the extent and number of missing teeth and whether the masticatory surface can be replaced by a prosthesis.

3. If limitation of inter-incisal range of motion, provide actual range in mm (i.e., 0-Xmm) and also provide lateral excursion (i.e., 0-Xmm).

4. Describe the extent of any bone loss of mandible, maxilla, or hard palate. For hard palate and maxilla bone loss, state whether replaceable by prosthesis.

D. Diagnostic and Clinical Tests:

Provide:

1. X-ray to determine extent of bone tissue loss.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Give etiology where there is loss of teeth due to loss of substance of body of maxilla or mandible.

Signature: it says not signed Date: it says not dated

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