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Tbi Dc 8045 - New Criteria Oct 2008
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carlie
For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
amended as set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
Subpart B--Disability Ratings
2. In Sec. 4.124a, in the table titled ``Organic Diseases of the
Central Nervous System,'' the entry for 8045 is revised in its entirety
and a new table titled ``Evaluation of Cognitive Impairment And Other
Residuals of TBI Not Otherwise Classified'' is added after the
``Organic Diseases of the Central Nervous System'' table, to read as
follows:
Sec. 4.124a Schedule of ratings--neurological conditions and
convulsive disorders.
* * * * *
Organic Diseases of the Central Nervous System
--------------------------------------------------------------------------
Rating
--------------------------------------------------------------------------
* * * * * * *
8045 Residuals of traumatic brain injury (TBI):
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
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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 Sec. 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 Sec. 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.
--------------------------------------------------------------------------
[[Page 54706]]
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
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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 Sec. 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.
* * * * * * *
--------------------------------------------------------------------------
Evaluation of Cognitive Impairment and Other Residuals of TBI Not
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Otherwise Classified
------------------------------------------------------------------------
Facets of cognitive impairment
and other residuals of TBI not Level of Criteria
otherwise classified impairment
------------------------------------------------------------------------
Memory, attention, 0 No complaints of
concentration, executive impairment of memory,
functions. attention,
concentration, or
executive functions.
1 A complaint of mild
loss of memory (such
as having difficulty
following a
conversation,
recalling recent
conversations,
remembering names of
new acquaintances, or
finding words, or
often misplacing
items), attention,
concentration, or
executive functions,
but without objective
evidence on testing.
2 Objective evidence on
testing of mild
impairment of memory,
attention,
concentration, or
executive functions
resulting in mild
functional impairment.
3 Objective evidence on
testing of moderate
impairment of memory,
attention,
concentration, or
executive functions
resulting in moderate
functional impairment.
Total Objective evidence on
testing of severe
impairment of memory,
attention,
concentration, or
executive functions
resulting in severe
functional impairment.
Judgment....................... 0 Normal.
1 Mildly impaired
judgment. For complex
or unfamiliar
decisions,
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occasionally unable to
identify, understand,
and weigh the
alternatives,
understand the
consequences of
choices, and make a
reasonable decision.
2 Moderately impaired
judgment. For complex
or unfamiliar
decisions, usually
unable to identify,
understand, and weigh
the alternatives,
understand the
consequences of
choices, and make a
reasonable decision,
although has little
difficulty with simple
decisions.
3 Moderately severely
impaired judgment. For
even routine and
familiar decisions,
occasionally unable to
identify, understand,
and weigh the
alternatives,
understand the
consequences of
choices, and make a
reasonable decision.
Total Severely impaired
judgment. For even
routine and familiar
decisions, usually
unable to identify,
understand, and weigh
the alternatives,
understand the
consequences of
choices, and make a
reasonable decision.
For example, unable to
determine appropriate
clothing for current
weather conditions or
judge when to avoid
dangerous situations
or activities.
[[Page 54707]]
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Social interaction............. 0 Social interaction is
routinely appropriate.
1 Social interaction is
occasionally
inappropriate.
2 Social interaction is
frequently
inappropriate.
3 Social interaction is
inappropriate most or
all of the time.
Orientation.................... 0 Always oriented to
person, time, place,
and situation.
1 Occasionally
disoriented to one of
the four aspects
(person, time, place,
situation) of
orientation.
2 Occasionally
disoriented to two of
the four aspects
(person, time, place,
situation) of
orientation or often
disoriented to one
aspect of orientation.
3 Often disoriented to
two or more of the
four aspects (person,
time, place,
situation) of
orientation.
Total Consistently
disoriented to two or
more of the four
aspects (person, time,
place, situation) of
orientation.
Motor activity (with intact 0 Motor activity normal.
motor and sensory system).
1 Motor activity normal
most of the time, but
mildly slowed at times
due to apraxia
(inability to perform
previously learned
motor activities,
despite normal motor
function).
2 Motor activity mildly
decreased or with
moderate slowing due
to apraxia.
3 Motor activity
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moderately decreased
due to apraxia.
Total Motor activity severely
decreased due to
apraxia.
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
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occasional headaches,
mild anxiety.
1 Three or more
subjective symptoms
that mildly interfere
with work;
instrumental
activities of daily
living; or work,
family, or other close
relationships.
Examples of findings
that might be seen at
this level of
impairment are:
intermittent
dizziness, daily mild
to moderate headaches,
tinnitus, frequent
insomnia,
hypersensitivity to
sound,
hypersensitivity to
light.
2 Three or more
subjective symptoms
that moderately
interfere with work;
instrumental
activities of daily
living; or work,
family, or other close
relationships.
Examples of findings
that might be seen at
this level of
impairment are: marked
fatigability, blurred
or double vision,
headaches requiring
rest periods during
most days.
Neurobehavioral effects........ 0 One or more
neurobehavioral
effects that do not
interfere with
workplace interaction
or social interaction.
Examples of
neurobehavioral
effects are:
Irritability,
impulsivity,
unpredictability, lack
of motivation, verbal
aggression, physical
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aggression,
belligerence, apathy,
lack of empathy,
moodiness, lack of
cooperation,
inflexibility, and
impaired awareness of
disability. Any of
these effects may
range from slight to
severe, although
verbal and physical
aggression are likely
to have a more serious
impact on workplace
interaction and social
interaction than some
of the other effects.
1 One or more
neurobehavioral
effects that
occasionally interfere
with workplace
interaction, social
interaction, or both
but do not preclude
them.
2 One or more
neurobehavioral
effects that
frequently interfere
with workplace
interaction, social
interaction, or both
but do not preclude
them.
3 One or more
neurobehavioral
effects that interfere
with or preclude
workplace interaction,
social interaction, or
both on most days or
that occasionally
require supervision
for safety of self or
others.
Communication.................. 0 Able to communicate by
spoken and written
language (expressive
communication), and to
comprehend spoken and
written language.
1 Comprehension or
expression, or both,
of either spoken
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language or written
language is only
occasionally impaired.
Can communicate
complex ideas.
2 Inability to
communicate either by
spoken language,
written language, or
both, more than
occasionally but less
than half of the time,
or to comprehend
spoken language,
written language, or
both, more than
occasionally but less
than half of the time.
Can generally
communicate complex
ideas.
3 Inability to
communicate either by
spoken language,
written language, or
both, at least half of
the time but not all
of the time, or to
comprehend spoken
language, written
language, or both, at
least half of the time
but not all of the
time. May rely on
gestures or other
alternative modes of
communication. Able to
communicate basic
needs.
Total Complete inability to
communicate either by
spoken language,
written language, or
both, or to comprehend
spoken language,
written language, or
both. Unable to
communicate basic
needs.
[[Page 54708]]
Consciousness.................. Total Persistently altered
state of
consciousness, such as
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vegetative state,
minimally responsive
state, coma.
------------------------------------------------------------------------
* * * * *
3. In Appendix A to Part 4, Sec. 4.124a, add diagnostic code 8045 in
numerical order to the table to read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946
* * * * *
------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------
* * * * *
4.124a...................... 8045 Criterion and evaluation
October 23, 2008.
* * * * *
------------------------------------------------------------------------
* * * * *
4. In Appendix B to Part 4, diagnostic code 8045 is revised to read as
follows:
Appendix B to Part 4--Numerical Index of Disabilities
* * * * *
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------
* * * * *
8045...................................... Residuals of traumatic brain
injury (TBI).
* * * * *
------------------------------------------------------------------------
* * * * *
5. In Appendix C to Part 4 under the heading for ``Brain'' remove
``Disease due to trauma'' and its diagnostic code ``8045''; and add in
alphabetical order a new heading ``Traumatic brain injury residuals''
and its diagnostic code ``8045''.
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[FR Doc. E8-22083 Filed 9-22-08; 8:45 am]
BILLING CODE 8320-01-P
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