Tbi Criteria - Schedule Of Rating Disability

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http://edocket.access.gpo.gov/cfr_2009/jul...38cfr4.124a.htm

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 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.........................

Evaluation of Cognitive Impairment and Subjective Symptoms

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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 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.....................