Catastrophically Disabled Veteran Evaluation

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CORRECTED COPY

Department of Veterans Affairs VHA DIRECTIVE 2004-067

Veterans Health Administration

Washington, DC 20420 November 22, 2004

CATASTROPHICALLY DISABLED VETERAN EVALUATION

1. PURPOSE: This Veterans Health Administration (VHA) Directive issues policy for the clinical evaluation and, as appropriate, placement of eligible veterans determined to be catastrophically disabled into Priority Group 4.

2. BACKGROUND

a. The “Veterans’ Health Care Eligibility Reform Act of 1996”, Public Law 104-262 required the Department of Veterans Affairs (VA) to establish and operate a system of annual patient enrollment and created seven Priority Groups. The “Department of Veterans Affairs Health Care Programs Enhancement Act of 2001,” Public Law 107-135 subsequently expanded the seven priority groups to eight with Priority Group 8 having the lowest priority.

b. Priority 4 status is given to veterans who are in receipt of increased pension based on a need of regular aid and attendance or by reason of being permanently housebound, and other veterans who are catastrophically disabled as determined by VHA. Benefits of Priority 4 inclusion include elevation of the veterans’ existing enrollment priority status and the opportunity to enroll and receive VA healthcare services for those who may otherwise be ineligible due to a Priority Group enrollment restriction.

(1) Veterans are considered to be catastrophically disabled who have a permanent severely disabling injury, disorder, or disease that compromises the ability to carry out the activities of daily living to such a degree that the individual requires assistance to leave the home or requires constant supervision to avoid physical harm to self or others as defined by Title 38 Code of Federal Regulations (CFR) Section 17.36 (e).

(2) VA Form 10-0383, Catastrophically Disabled Veteran Evaluation, may be initiated at the request of the veteran, representative of the veteran, or the facility. VA Form 10-0383 can be found on the VA Forms website at: vaww.va.gov/vaforms. It can be used for local reproduction. Since it is a low use form, it will not be stocked by the Hines Service and Distribution Center (formerly known as the Publications Depot).

c. Effective January 17, 2003 VA restricted the enrollment of Priority 8 veterans applying for enrollment on or after that date. Veterans currently enrolled in Priority Groups 5 though 8, or those potentially not eligible for enrollment based on the enrollment decision, may continue to apply for enrollment into Priority 4 based on being catastrophically disabled.

3. POLICY: It is VHA policy to provide a Catastrophically Disabled Veteran Evaluation within 35 days of request.

THIS VHA DIRECTIVE EXPIRES NOVEMBER 30, 2009 VHA DIRECTIVE 2004-067 CORRECTED COPY November 22, 2004 2

NOTE: To request a Catastrophically Disabled Veteran Evaluation, veterans may call the Health Benefits Service Center, a toll-free number, 1-877-222-VETS (-8387), or the enrollment coordinator at their local VA medical center. Movement from a lower priority group to Priority Group 4 does not change the veteran’s applicable co-payment responsibility.

4. ACTION

a. Medical Center Director. Each medical facility Director is responsible for ensuring that:

(1) The Catastrophically Disabled Veteran Evaluation determines whether the veteran is catastrophically disabled and therefore eligible for inclusion in priority category 4. Health care facilities are encouraged to initiate Catastrophically Disabled Veteran Evaluations for known veteran groups whose conditions clearly indicate potential eligibility for this enhanced enrollment status, such as veterans participating in Spinal Cord Injury Programs.

(2) Appropriate staff involved in the Catastrophically Disabled Veteran Evaluation are properly trained and knowledgeable in the following processes (see Att. B):

(a) Upon request, the facility enrollment coordinator or designee, must initiate VA Form 10-0383, for each veteran requesting such evaluation. The enrollment coordinator, or designee, must obtain available VA clinical records and/or records provided by the veteran and have them reviewed by an appropriate clinician. If sufficient documentation is available from the medical records to determine the catastrophically disabled status, VA Form 10-0383 is completed, front and back, a recommendation made, and the complete package forwarded to the Chief of Staff, or equivalent clinical representative, for approval or disapproval of the recommendation, or:

(b) If sufficient information is not available, the enrollment coordinator, or designee, forwards the request for evaluation to the appropriate designated examining area (e.g., Compensation and Pension (C&P), Physical Medicine and Rehabilitation Service (PM&RS), a specialty clinic, or a primary care provider). Upon completion of the evaluation, the examining clinician must complete and return VA Form 10-0383 to the enrollment coordinator, or designee, who forwards the completed package to the Chief of Staff, or equivalent clinical representative, for approval or disapproval of the recommendation.

1. If approved, written notification is sent to the veteran and/or the veteran’s representative.

2. If disapproved, written notification, including appeal rights, is sent to the veteran and/or representative. It is recommended that telephonic contact be made as well.

NOTE: See Attachments C through F for appropriate sample letter usage. All correspondence, including VA Form 10-0383 and any completed assessment tool, must be placed, or scanned, into the veteran’s medical record.

© Appropriate information as well as data from VA Form 10-383, is entered into the Veterans Health Information and Technology Architecture (VistA). CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 3

b. Office of the Assistant Deputy Under Secretary for Health (10A5). The Office of the Assistant Deputy Under Secretary for Health is responsible for collecting Catastrophically Disabled Veteran Evaluation data for reporting and analysis purposes. Results are posted on http://vaww.va.gov/vhaopp . This data is collected via appropriate VA Form 10-0383 VistA entries and includes:

(1) Number of new catastrophically disabled evaluations completed, both by record review and clinical examination.

(2) Number of cumulative catastrophically disabled evaluations completed, both by record review and clinical examination.

(3) Number of total estimated or potential catastrophically disabled evaluations.

5. REFERENCES: Public Law 104-262.

6. FOLLOW-UP RESPONSIBILITY: The Chief Business Office (16) is responsible for the contents of this Directive. Questions may be directed to (202) 254-0406. NOTE: For questions regarding the clinical evaluation or instruments, criteria, and threshold information, contact the VISN Clinical Manager (10N) or the Office of Patient Care Services (11) at (202) 273-8474.

7. RESCISSION: VHA Directive 2001-025, is rescinded. This VHA Directive expires November 30, 2009.

S/Jonathan B. Perlin, MD, PhD MSHA, FACP

Acting Under Secretary for Health

Attachments

DISTRIBUTION: CO: E-mailed 11/242004

FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 11/ 24/2004

CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 A-1

ATTACHMENT A

DEFINITION OF CATASTROPHICALLY DISABLED

1. Catastrophically disabled (CD) means to have a permanent severely disabling injury, disorder, or disease that compromises the ability to carry out the activities of daily living (ADL) to such a degree that the individual requires personal or mechanical assistance to leave home or bed or requires constant supervision to avoid physical harm to self or others.

2. A veteran may meet the initial CD requirement by a:

a. Clinical evaluation of the patient’s medical records that documents that the patient previously met the criteria set forth in following paragraph 3 and continues to meet such criteria (permanently), or would continue to meet such criteria (permanently) without the continuation of on-going treatment; or

b. Current medical examination that documents that the patient meets the criteria set forth in following paragraph 3 and will continue to meet them, or would continue to meet such criteria (permanently) without the continuation of on-going treatment.

3. This definition is met if an individual has been found, by the Chief of Staff (or equivalent clinical official) at the Department of Veterans Affairs (VA) facility where the individual was examined, to have a permanent condition specified in following subparagraphs 3a, 3b, or 3c:

a. One of the permanent diagnoses found on website: http://vaww.va.gov/vhaopp/report01/report01.htm (see “View CD Diagnoses”).

OR

b. A condition resulting from two of the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) procedure codes, or associated V codes when available, or Current Procedural Terminology (CPT) codes provided the two amputation procedures were not on the same limb. These codes can be found at the following website: http://vaww.va.gov/vhaopp/report01/report01.htm (see “View CD Diagnoses”).

OR

c. One of the following permanent conditions:

(1) Dependent in three or more ADLs; i.e., eating, dressing, bathing, toileting, transferring, incontinence of bowel and/or bladder, with at least three of the dependencies being permanent with a score of 1, using the Katz scale. NOTE: The Katz Index of ADL assigns a maximum of 18 points across all six ADLs. The most dependent rating on each ADL is a 1, and an intermediate functional limitation is a rating of 2, with independence rated as 3. To be catastrophically disabled, the veteran must have a rating of 1 on a minimum of three permanent ADLs. For example, a veteran dependent in all ADLs would have a total Katz score of 6. VHA DIRECTIVE 2004-067 CORRCETED COPY November 22, 2004 A-2

Similarly, a veteran dependent in three ADLs and needing less assistance in three other ADLs would score 9.

(2) A score of 10 or lower using the Folstein Mini-Mental State Examination (MMSE). NOTE: The MMSE has a maximum assignment of 30 points across eleven measures. A score of less than 10 is consistent with severe cognitive impairment. To qualify for CD status, there must be documentation in addition to the MMSE score of 10 or lower, showing that the patient has a permanent cognitive impairment. To show that the impairment is permanent, the reversible causes of cognitive impairment need to be ruled out. A common example is a delirious patient who may score very badly on the MMSE, but improve once the source of delirium is treated. It is also important for evaluators to remember that a low MMSE score by itself is not diagnostic (i.e., it is not specifically diagnostic of dementia), but it is an indication of cognitive impairment that warrants further evaluation.

(3) A score of 2 or lower on at least four of the thirteen motor items using the Functional Independence Measure (FIM). NOTE: The FIM contains eighteen measures in six domains. The thirteen motor items are in four domains: self-care; sphincter control; transfers; and locomotion. The scores across all these domains range from needing a helper because of complete dependence (score of 1 for total assistance and a score of 2 for maximal assistance), with intermediate scores 3 through 5 for modified independence, to scores 6 or 7 when no helper is needed. To be CD, the veteran must have a score of 2 or lower on at least four permanent conditions of the thirteen motor items using the FIM.

(4) A score of 30 or lower using the Global Assessment of Functioning (GAF). NOTE: The GAF is taken directly from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32, except that VHA only includes scores from 1 to 100, excluding 0 (insufficient information).

(a) GAF is a 100-point scale divided into ten defined levels, with higher scores indicating a higher overall level of functioning. For example, the Description of the GAF level 21 to 30 is as follows: “Behavior is considerably influenced by delusions or hallucination or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, no home or no friends).”

(b) GAF is to be used only to reflect psychological, social, and occupational functioning. Impairment in functioning due to physical illness or environmental limitations are not to be taken into consideration in using this scale. The scale rates both functioning and, particularly in the higher ratings, the severity of symptoms due to a mental disorder. Using GAF for documenting the CD may be only done in the context of a mental disorder considered to be of a permanent nature. For example, a patient with a serious suicidal attempt might well rate a score under 30, but generally within a few days or weeks will return to a much higher level both symptomatically and functionally. CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 A-3

4. References

a. Katz S, Downs TD, Cash HR, et al. “Progress in the Development of the Index of ADL,” The Gerontologist. Part I:20;1970.

b. Juva K., Sulkava R., Erkinjuntti T., et al. “Staging the Severity of Dementia: Comparison of Clinical (CDR, DSM III-R), Functional (ADL, IADL) and Cognitive (MMSE) Scales,” Acta Neurologica Scandinavica. 90:293;1994.

c. Folstein MF, Folstein S, McHugh PR. “Mini-mental State: A Practical Method for Grading the Cognitive State of Patients for the Clinician,” Journal of Psychiatric Research. 12:189; 1975. CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 B-1

ATTACHMENT B

CATASTROPHICALLY DISABLED (CD) EVALUATION PROCESS

(35 CALENDAR DAYS)

(Yes)

(No)

(No)

(Yes)

(Yes/No)

Veteran requests a CD evaluation.

If request is through the Veterans Health Administration (VHA) Benefits Service Center, the call will be transferred to the preferred facility enrollment office where the clinical and data capture process begins.

VHA or non-VHA medical records available?

Clinical evaluation based on available records.

Able to evaluate?

Appointment made and

new records initiated.

Veteran evaluated clinically.

Meets criteria ?

Chief of Staff or designee decision.

Facility letter of acceptance or denial letter mailed to veteran.

Determination/approval request completed.

Copy of letter sent will be placed in the patient’s permanent record and all appropriate data fields are completed. CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 C-1

ATTACHMENT C

VETERAN REQUESTED CATASTROPHICALLY DISABLED (CD) EVALUATION

SAMPLE OF WRITTEN NOTIFICATION FOR A VETERAN

WHO IS DETERMINED TO BE CD

NOTE: If the Catastrophically Disabled (CD) determination is that the veteran is CD, written notification of the outcome must be sent to the veteran from the Department of Veterans Affairs (VA) health care facility Chief of Staff using the following letter sample.

(Date)

(Name)

(Address)

(City, State, Zip Code)

Dear ________

The recent review you requested of medical records and/or a catastrophically disabled (CD) examination shows that you meet the definition of a CD veteran for Department of Veterans Affairs (VA) health care purposes. Based on this determination, your enrollment priority group should change to Priority Group 4. Official notification of any changes in your priority group will be sent in a separate letter.

Veterans enrolled in Priority Group 4 are eligible for all needed services included in the Medical Benefits Package. Veterans previously subject to co-payments will still be required to agree to pay those co-payments after moving to Priority Group 4. If you have any questions, feel free to call the enrollment office at _________(phone number)________ (or the appropriate locally designated office).

Sincerely yours,

___________(Signature)____________

VA Health Care Facility Chief of Staff CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 D-1

ATTACHMENT D

VETERAN REQUESTED CATASTROPHICALLY DISABLED (CD) EVALUATION

SAMPLE OF WRITTEN NOTIFICATION FOR A VETERAN

WHOSE ENROLLMENT PRIORITY IS NOT CD

NOTE: If the Catastrophically Disabled (CD) determination is that the veteran is not CD, written notification of the outcome must be sent to the veteran from the Department of Veterans Affairs (VA) health care facility Chief of Staff using the following letter sample.

(Date)

(Name)

(Address)

(City, State, Zip Code)

Dear ________

You recently requested a medical record review and/or a catastrophically disabled (CD) examination to determine if you meet the criteria to be classified as a CD veteran for Department of Veterans Affairs (VA) health care purposes.

A thorough review was conducted by the VA medical facility located at ______(facility address)________ and the determination has been made that you do not meet the criteria to be classified as catastrophically disabled. I reviewed your medical records and/or your most recent CD examination results. Based upon this review I have confirmed that you do not meet the criteria of a CD veteran for the following reasons:

NOTE: This letter must contain both the reasons for the decision and a summary of the evidence considered by VA.

If you disagree with this decision, you may appeal it. You may choose one or both of the following options.

a. You may seek reconsideration of this decision. Your written request for reconsideration needs to be addressed to the VA health care facility Director, at __(name of facility)__ . Your request for reconsideration must be postmarked or received within 1 year of the date of this letter; and/or

b. You may appeal the decision to the Board of Veterans’ Appeals as outlined in enclosed VA Form 4107VHA, Your Rights to Appeal Our Decision. As part of this process, you will have a right to a personal hearing and the right to representation. To begin the appeal process, you or your representative need to express your dissatisfaction or disagreement with this decision in a written communication to this facility (a Notice of Disagreement). Your Notice of VHA DIRECTIVE 2004-067 CORRECTED COPY November 22, 2004 D-2

Disagreement must be postmarked or received no later than 1 year after the date of this letter and needs to be addressed to ____________________.

We regret that a more favorable decision could not be reached concerning your request for CD status. If you have any questions, feel free to call the enrollment office or your VA health care provider at _________(phone number)________ (or the appropriate locally designated office).

Sincerely yours,

___________(Signature)____________

VA Health Care Facility Chief of Staff

Enclosure CORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 E-1

ATTACHMENT E

FACILITY INITIATED MEDICAL RECORD REVIEW

SAMPLE OF WRITTEN NOTIFICATION FOR A VETERAN

WHOSE ENROLLMENT PRIORITY

CHANGES TO CATASTROPHICALLY DISABLED (CD)

NOTE: If the Catastrophically Disabled (CD) determination is that the veteran is CD, written notification of the outcome must be sent to the veteran from the Department of Veterans Affairs (VA) health care facility Chief of Staff using the following letter sample.

(Date)

(Name)

(Address)

(City, State, Zip Code)

Dear ________

A recent review of your medical records and/or a CD examination shows that you meet the definition of a CD veteran for Department of Veterans Affairs (VA) health care purposes. Based on this determination, your enrollment priority group should change to Priority Group 4. Official notification of any changes to your priority group will be sent in a separate letter.

Veterans enrolled in Priority Group 4 are eligible for all needed services included in the Medical Benefits Package. Veterans previously subject to co-payments will still be required to agree to pay those co-payments after moving to Priority Group 4. If you have any questions, feel free to call the enrollment office or your VA health care provider at _________(phone number)________ or ___the appropriate locally-designated office___

Sincerely yours,

___________(Signature)____________

VA Health Care Facility Chief of StaffCORRECTED COPY VHA DIRECTIVE 2004-067 November 22, 2004 F-1

ATTACHMENT F

FACILITY INITIATED MEDICAL RECORD REVIEW

SAMPLE OF WRITTEN NOTIFICATION FOR A VETERAN

WHEN A CATASTROPHICALLY DISABLED (CD) DETERMINATION

CANNOT BE MADE BASED UPON A MEDICAL RECORD REVIEW

(FOR VETERANS WITH A KNOWN PRIORITY GROUP)

NOTE: If the Catastrophically Disabled (CD) determination for a veteran who has an Enrollment Priority Group cannot be made based on a medical record review, written notification of the outcome must be sent to the veteran from the Department of Veterans Affairs (VA) health care facility Chief of Staff using the following letter sample. The letter encourages the veteran to schedule an appointment for a CD examination in order to complete the CD evaluation process.

(Date)

(Name)

(Address)

(City, State, Zip Code)

Dear ________

Our facility has recently completed a medical record review to determine if you meet the criteria to be classified as catastrophically disabled (CD) for Department of Veterans Affairs (VA) health care purposes. Based on the current information in your medical record, we are not able to complete our CD determination.

If you feel that you may qualify for CD status, we would encourage you to contact our enrollment office, or the appropriate locally designated office, for more information and to schedule an appointment for a CD examination at ______(phone number)__________.

Sincerely yours,

___________(Signature)_______________

VA Health Care Facility Chief of Staff