hypertension Vha Directive 2012-025 - Ace, Can Be C&p

[carlie]

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2790

Department of Veterans Affairs VHA DIRECTIVE 2012-025

Veterans Health Administration

Washington, DC 20420 September 17, 2012

ACCEPTABLE CLINICAL EVIDENCE (ACE) TO SUPPORT THE COMPENSATION

AND PENSION (C&P) DISABILITY EVALUATION PROCESS

1. PURPOSE: This Veterans Health Administration (VHA) Directive defines the policy for

responding to requests from Veterans Benefits Administration (VBA) for compensation and

pension (C&P) disability evaluations and appropriate use of the Acceptable Clinical Evidence

(ACE) process. AUTHORITY: Title 38 United States Code 5103A(d); and Title 38 Code of

Federal Regulations 3.159©(4).

2. BACKGROUND: ACE may be used whereby clinicians may consider the medical evidence

currently in existence and a Veteran’s claims file, supplemented by a telephone interview if

necessary, and use that existing evidence to prepare a Disability Benefits Questionnaire (DBQ)

instead of requiring some Veterans to be examined in-person.

a. VHA provides Veterans with disability evaluations allowing them to obtain the benefits

for which they are eligible. This process is a major VHA responsibility and of great importance

to Veterans and stakeholders.

b. The ACE process does not replace existing VHA policy providing guidance on the C&P

disability evaluation process to obtain medical information to assist in the adjudication of claims.

This Directive provides the VHA clinician with information about the ACE process.

c. VBA determines whether additional medical evidence is required to decide a claim, unless

the Board of Veterans’ Appeals (BVA), United States (U.S.) Court of Appeals for Veterans

Claims, or U.S. Court of Appeals for the Federal Circuit has remanded a claim and requires an

in-person evaluation or opinion.

d. Unless VBA personnel have specifically required that an examination be conducted, once

VBA has requested an evaluation or opinion and provided all available medical information to

VHA, a VHA C&P disability clinician reviews the request and, if use of the ACE process is

determined by the clinician to be appropriate, completes the DBQ using the ACE process, or

refers the request to the appropriate VHA C&P disability clinician to complete the DBQ using

the ACE process. The ACE process may include a telephone interview to supplement the

available records. If additional information is required, the ACE process is not used, and the

Veteran is scheduled for an in-person medical examination or telehealth examination. When the

ACE process is used, the clinician must ensure the appropriate entry is made on the DBQ to report

the use of the ACE process, and must explain, in the DBQ Remarks section, the source of the

clinical evidence relied on to complete the DBQ.

e. There will be some claims for which an ACE review cannot be done; those claims are

clearly identified by VBA in the C&P disability evaluation request. For example, the ACE

process cannot be used if a BVA Remand orders that an examination be conducted.

THIS VHA DIRECTIVE EXPIRES SEPTEMBER 30, 2015 VHA DIRECTIVE 2012-025

September 17, 2012

2

f. Definitions

(1) Examination. An examination is a medical professional’s personal observation and

evaluation of a claimant. It can be conducted in person or by means of telehealth.

(2) Evaluation. An evaluation is an assessment of the medical evidence, which may involve

conducting an examination, providing an opinion, or both.

(3) Opinion. An opinion refers to a medical professional’s statement of findings and views,

which may be based on review of the claimant’s medical records or personal examination of the

claimant, or both.

3. POLICY: It is VHA policy that effective October 15, 2012, VHA C&P disability clinicians

must use the ACE process to respond to VBA requests for medical evaluations when the VHA

C&P disability clinician determines it is appropriate to do so, based on the medical evidence in

the medical record, supplemented by a telephone interview if necessary.

4. ACTION

a. Under Secretary for Health. The Under Secretary for Health is responsible for the

quality and timeliness of VHA C&P disability evaluation process, and ensuring that resources

are allocated in support of the process.

b. Office of Disability and Medical Assessment. The Office of Disability and Medical

Assessment is responsible for:

(1) Ensuring implementation of, and compliance with, this Directive.

(2) Establishing monitors as part of DMA’s audit review by December 30, 2012.

(3) Providing guidance through regular conference calls, web-based training, etc., to VHA

C&P disability clinicians, in cooperation with Patient Care Services and VBA.

(4) Ensuring that medically accurate training on the ACE process is provided to the

appropriate VHA clinicians.

(5) Making recommendations for process changes and improvements.

(6) Reviewing selected ACE evaluations to ensure medically-appropriate content.

c. Veterans Integrated Service Network (VISN) Director. Each VISN Director is

responsible for:

(1) Ensuring that requirements for training, credentialing, and privileging are completed.

(2) Ensuring that a Veteran-centric approach to the ACE process is established. VHA DIRECTIVE 2012-025

September 17, 2012

3

(3) Ensuring that close collaboration with VBA regional offices is established and

maintained.

(4) Monitoring the usage of the ACE process within the VISN.

d. Facility Director. Each Facility Director is responsible for:

(1) Ensuring that ACE is conducted, when appropriate, in response to a C&P disability

evaluation request received by the facility.

(2) Ensuring ACE reviews are conducted only for evaluation requests for Veterans within

the VHA facility’s VISN. There are limited circumstances when VHA clinicians conduct

reviews of medical evidence from VHA facilities outside their VISN. For example, a Pension

Management Center, a Resource Center, or a Restricted Access Claims Center could request

local VHA clinicians to review records from a different VISN. With that exception, however,

VHA clinicians using the ACE process only review records consistent with the regional

responsibilities of the clinician’s facility.

(3) Ensuring, upon receipt of a request for a C&P disability evaluation or opinion, the VHA

C&P disability evaluation clinician decides if ACE is appropriate based on a review of the

medical record(s) and claims file, supplemented by a telephone interview if necessary. NOTE:

A request may be for multiple disability evaluations for one Veteran.

(4) Ensuring conditions that may be successfully addressed in an ACE review include, but

are not limited to:

(a) Prostate and other genitourinary conditions, which have already been assessed.

(b) Some oncology cases, whether the cancer is active and/or primary site identification, if

metastasized.

© Ischemic Heart Disease, for which a functional assessment may be done by a telephone

interview.

(d) Tinnitus can sometimes be assessed in a telephone interview when a current audiometric

examination is already documented.

(e) Hypertension can be addressed by the ACE method if the record contains current blood

pressure readings.

(f) Pulmonary conditions.

(5) Ensuring medical opinions are provided using the ACE process when the existing

records provide adequate information. Opinions are provided for:

(a) Clarifying a previous medical evaluation, VHA DIRECTIVE 2012-025

September 17, 2012

4

(b) Clarifying a previous medical opinion, or

© Providing a new opinion.

(6) Ensuring the ACE process is not used for mental health disability examinations.

(7) Ensuring the DBQ indicates when the ACE process is used, and identifies the materials

reviewed to complete the DBQ or render the opinion. The DBQ contains a box that must be

checked if the DBQ was completed using the ACE process.

(8) Ensuring if the ACE process involves obtaining information from a Veteran by telephone

interview, current VHA policy must be followed, including the procedures VHA staff need to

use to authenticate the identity of individuals requesting medical care, treatment, or services at

VHA. NOTE: These identification procedures ensure that the Veteran is the person being

interviewed.

(9) Ensuring that if the ACE process involves telehealth, the evaluation is conducted in

accordance with established VHA telehealth policy including policies and procedures located on

the VA Telehealth Services Web site at: http://vaww.telehealth.va.gov/index.asp. NOTE: This

is an internal Web site and is not available to the public.

(10) Ensuring that adequate methods of workload documentation are used to support time

allocations and staffing levels to complete evaluations in a timely and sufficient manner, and in a

way that can be aggregated in Decision Support System.

5. REFERENCES: VHA Handbook 1601E.01.

6. FOLLOW-UP RESPONSIBILITY: The Office of Disability and Medical Assessment

(10NC8) is responsible for the contents of this VHA Directive. Questions may be referred to the

Director, Clinical Programs and Administrative Operations at 202-461-6699.

7. RESCISSION: None. This VHA Directive expires September 30, 2015.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION: E-mailed to the VHA Publications Distribution List 9/18/2012

[Navy04]

Carla,

As usual people on here like you, Berta and Megh have listed on here so much useful information. You guys are very dedicated to helping a lot of us Vets that are just tired of being tired. Thanks again and hope you have a safe weekend.