Tbi C&p Yesterday

[bufloguy]

Just had my C&P for TBI due to MVA 20 years ago. The examiner stated she read my c-file, and thanked me for putting together such a "great" claims package. She asked a few questions about the accident itself, memory, headaches, ect. Then checked my reflexes, vision, and asked about my sense of smell. On my way out the door, she stated that I was SC for TBI, and the RO willl decide my %. All totaled the exam was 7:36.

Does this sound right?

[bufloguy]

Got the Exam back, and I'm not sure how it reads:

Printed for data from 04/08/2009 to 10/05/2009

*********************** CONFIDENTIAL SUMMARY**********************

-------------------------- CP - Compo & Pen. Exams ---------------------------

09/29/2009 TRAUMATIC BRAIN INJURY (TBI)

Priority of Exam: INCREASE

Examining provider:

Approved By:

Examination results:

EXAM TYPE: Traumatic brain injury.

The Veteran is a 42-year-old male. He was in the military from 1985-1991. His service file was provided and it was reviewed.

He had two motor vehicle accidents that both occurred in 1989. In the first motor vehicle accident, he has no memory of the events. He said he had loss of

consciousness. He said he was seen in the emergency room. He said in the second motor vehicle accident he lost consciousness for three hours. He said

he had a three-day stay in the hospital. He says he has no memory of this accident either. The severity rating of the traumatic brain injury at the time

of the injury is mild for the first one and moderate for the second incident. The condition has stabilized.

He complains of headaches. The headaches occur about 15 times per month. They are moderate to severe in nature. They last all day. About three times a

month he is unable to function because of the headache. He currently takes Excedrin Migraine. They resemble migraines. He denies dizziness, vertigo,

weakness, or paralysis. He says he has difficulty falling asleep. He has insomnia. He has taken medications in the past with minimal benefit. This

occurs on a nightly basis. He complains of daytime fatigue and malaise. He complains of mobility and balance problems. He described mild to moderate

memory impairment. He describes short-term memory problems. He says he has decreased attention and concentration. He denies any problems with executive

functioning. He has no speech or swallowing difficulties, pain, bowel problems, or bladder problems. He complained of anxiety and depression. He

denied erectile dysfunction, sensory changes, vision problems, hearing problems, decreased sense of taste or smell, or seizures. He described

hypersensitivity to both sound and light. He complained of irritability and restlessness. He has no signs of autonomic dysfunction, endocrine dysfunction,

or cranial nerve dysfunction. His symptoms are stable. His current treatment includes Excedrin Migraine. He says that his daily activities are affected

because of his frequent headaches that lead to time off from work.

PHYSICAL EXAMINATION: MOTOR: Power, tone, and bulk (5/5) is normal in the deltoids, biceps, triceps, wrist extensor, flexors, small muscles of the hand,

iliopsoas, hamstring, quadriceps, gluteal, foot dorsi flexors and plantar flexors. His reflexes are +2. Sensory exam was normal. Gait was normal.

There was no spasticity or abnormal cerebellar signs. Autonomic nervous system was normal. CRANIAL NERVES: Visual fields full. Extraocular movements

intact. Pupils equal, round, and reactive to light. Funduscopic exam normal. Sensation of the face normal. Tongue and uvula normal. Trapezius and

sternocleidomastoid normal. Normal swallowing. Normal hearing.

MINI MENTAL

STATUS: 28/30. Psychiatric screening was normal. Vision and hearing screening normal. SKIN: Normal. ENDOCRINE/AUTONOMIC: Normal. No other abnormal physical findings.

He underwent neuropsychological evaluation on 10/10/08. He was found to have difficulties with impairment of working memory, visual and motor scanning,

sequencing, and verbal and visual memory. He also has symptoms of PTSD and depression.

I. Memory, attention, concentration, and executive functions; see objective evidence of memory impairment.

II: Judgement. A. Normal.

III: Social interaction. A. Appropriate.

IV: Orientation. A. Always oriented.

V: Motor activity. A. Normal.

VI: Visual and spacial orientation. C. Moderate impaired.

VII: Subjective symptoms. B. Three or more.

VIII: Neurobehavioral affects. B. One or more.

IX: Communication. A. Able to communicate.

X: Consciousness. A. Normal.

IMPRESSION: The Veteran with traumatic brain injury. He has the capacity to handle his VA benefit payments:

[Wings]

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On the surface, the C&P Examiner appears to have decided "TBI, Moderate Impairment". It appears there is definate, moderate neurological/cognative impairment. The examiner has otherwise noted "normal" findings in the emotional and physical aspects of your TBI. I do not know if your headaches will be rated separately. Someone else will chime in. ~Wings

SEE

38 CFR 4.124a Schedule of ratings—neurological conditions and convulsive disorders.

8045 Residuals of traumatic brain injury (TBI) [Diagnostic Code 8045]:

There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation.

Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.”

Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table.

Evaluate emotional/behavioral dysfunction under §4.130 (Schedule of ratings–mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.”

Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions.

The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under §4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations.

Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc.

Evaluation of Cognitive Impairment and Subjective Symptoms

The table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling.

Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets.

If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet.

Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified” with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition.

Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation.

Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet.

Note (4): The terms “mild,” “moderate,” and “severe” TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045.

Note (5): A veteran whose residuals of TBI are rated under a version of § 4.124a, diagnostic code 8045, in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran’s disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable.

[timetowinarace]

Okay, main part the rater is going to look at, other than the SC wich she seems to have made clear, is this.

"I. Memory, attention, concentration, and executive functions; see objective evidence of memory impairment.

II: Judgement. A. Normal.

III: Social interaction. A. Appropriate.

IV: Orientation. A. Always oriented.

V: Motor activity. A. Normal.

VI: Visual and spacial orientation. C. Moderate impaired.

VII: Subjective symptoms. B. Three or more.

VIII: Neurobehavioral affects. B. One or more.

IX: Communication. A. Able to communicate.

X: Consciousness. A. Normal.

IMPRESSION: The Veteran with traumatic brain injury. He has the capacity to handle his VA benefit payments:"

The highest facet she gave was on VI: Visual and spacial orientation. "C. Moderate impaired." C would equal a 2 or 40% I posted the guide for this below. Also from the rating criteria "For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet". So, you should get a minimum rating of 40% under 8045.

Visual spatial orientation 0 Normal.

1 Mildly impaired. Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system).

2 Moderately impaired. Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS (global positioning system).

3 Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system).

Total Severely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment.

Subjective symptoms 0 Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples are: mild or occasional headaches, mild anxiety.

The only 'problem' I see with your exam report is that she leaves number one open to the raters interpretation. "I. Memory, attention, concentration, and executive functions; see objective evidence of memory impairment." So when she said it was up to the rater as to your percentage she meant it literally. She refered the rater to the neurocognative testing rather than assigning a level of impairment herself. The problem is, raters are not neuro-psychologists and cannot interpret these tests. That said, it may work out, you will have to wait and see.

The news is, I can't imagine you getting less than 40% by this C&P alone. But, I'm not a rater. I don't know what you think your percentage should be but it will have to come from the first facet that the examiner left up to the rater. I think you could NOD based on the fact the rater did not have an opinion from the examiner on the memory facet to base a rating on.

Also, you should get a seperate rating for migraines. All the information, the DX and severity for migraines is in this report.

Yep, I have more. The examiner stated you complained of depression and anxiaty. If you are rated for tbi without a C&P for these issues and not given a seperate rating for them, you need to file a claim with the effective date as the day RO recieved this exam.

And a note for Wings. The C&P eximiner designation of a mild tbi for the first accident and moderate tbi for the second is a desgnation for the "type" of tbi and is useless for rating purposes. From the regs;

Note (4): The terms “mild,” “moderate,” and “severe” TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045.

Edited October 6, 2009 by timetowinarace

[Wings]

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Time, Thanks for that note to me. Since the veteran reports anxiety and depression, and you rightly suggest a separate C&P Exam for Mental Disorders; wouldn't this C&P Examiner have been required to submit a GAF score? Also, she did not comment on 'occupational impairment'? Is the veteran working? ~Wings

[timetowinarace]

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Time, Thanks for that note to me. Since the veteran reports anxiety and depression, and you rightly suggest a separate C&P Exam for Mental Disorders; wouldn't this C&P Examiner have been required to submit a GAF score? Also, she did not comment on 'occupational impairment'? Is the veteran working? ~Wings

No problem.

Well, my opinon on the GAF would be no, the examiner would not be required to submit a GAF. The reason is the examiner was assesing(or should have been) cognative dissorder and other residuals wich is not a mental or mood dissorder. The examiner was not and did not examin the veteran for depression and anxiaty but made note of it in the exam. A GAF would be appropiate for a mental condition but is not suitable for a cognative dissorder because a person can have cognative issue and be quite happy(most of us know someone that is quite cognatively challeged that allways have a smile on their face).

What is supposed to happen by the 8045 code is if the RO has a report of mood disorder due to tbi, a C&P must be ordered and a seperate rating assigned. A GAF would be assigned at this time.

I think the veteran is working(I'm not positive). If the veteran is working, of course there will be no opinion from the examiner whether or not he's employable.

I hope that answers your questions.

[bufloguy]

Thanks Time and Wings for the insight!

Wings, yes I am working, but having a hard time, I also have PTSD from the accident, and besides haviing a hard time driving, and having issues with remembering how to do my job, I have developed a nasty temper. GAF is normally reported arround 50. I filed the claim for PTSD at the same time as TBI, but for some reason I haven't had the PTSD C&P scheduled yet.

Time, thanks for pointing out the poss NOD on the memory issues esp since my memory is the bigest issue with the TBI.