Mh C&p In, Some Questions About Symptoms Noted Vs. Progress Notes

[brokensoldier244th]

I got my MH C&P notes back today, and as I peruse them I don't see too much that is glaringly off until I get to the "Symptoms" section in Section II, Clinical notes. Under the list of symptoms, only Depressed Mood is marked [X]. Nothing about disturbances of motivation or mood, disturbances of sleep, mild memory loss-things that are in my treatment notes with my Psychologist. Under the "Occupational Social Impairment" section he checked: "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation".

Tossing and turning, mind-mapping to keep thing straight, and my lack of motivation for social settings is noted in the write up under "current mental health", though. I just hope that stuff typed out in block gets read, too, and not just the things that are 'X'd off.

It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23) when my normal treatment notes from early April to present designate it as recurrent. How does a rater take that and run with it?

Is it normal for there to only have 1 thing marked in that entire symptoms section, even though the instructions state to check any and all symptoms related to the diagnosis? The rating isn't just based off of the checklist, is it? They will look at my psych notes,etc as well, where these things are noted? I thought the C&P was to take that into account in their overall write up, summarizing it, if you will, but maybe not. Is there going to be any weirdness with having only a single GAF when my clinician uses SOAP style notes with no GAF scores? (thus, no pattern)

My Axis(s) were listed as:

Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)

Diagnosis 2 (none)

Axis II Nothing listed

Axis III Medical diagnois-C&P records

Axis IV

Service related lumbar spine and sciatic nerve

GAF score 58

"There is no history of mental health hospitalization. The veteran was started on Sertraline by the physician initially for PME and then over time he started taking that daily for his mood, 1/2 tab daily"

"The veteran is married, 4 children. The veterans wife is employed as asst. manager of a movie theater. The veteran noted that often times they watch DVR or rental movies for family activity. The veteran noted that usually after the new movies have been out a few weeks they are more likely to do to movies when there will be less of a crowd."The veteran noted that his children are involved in [activities] and that he is involved, his wife does the majority of those activities."

"The veteran noted that Sertraline has calming effect upon his emotions and thought process. The veteran noted that he has been trying to work on physical prowess by exercising but that Physical Therapy said he was working too hard and in a manner that would not be conducive to reduction in pain. The veteran has avoided narcotic pain medication as he does not want to further dull his faculties. the veteran does not that there are times where he does not have an appetite and forgets to eat. The veterans energy level has been low to poor. The veteran noted that he will "mind map" to keep his clientele straight. The veteran has difficulty getting comfortable at night. The veteran tosses and turns repeatedly during the night. The veteran noted that he tends to be regimented and structured so as to try to contain the depressive symptomology.

The veteran noted that hsi sex drive is "not really...we cuddle, we dont' have sex......I take drugs for it, but then I don't 'want to'....". The veteran does not feel hopeless-he says that is why he sees his psychologist. the veteran does have some time he feels helpless. The veteran knows that his back pain "is going to be a lifetime thing. I get sick of it...i get tired of it hurting...i get tired of people asking why I don't spend time with them or do things with them... because there are days i can't get off the couch."

The veteran has friends "and we do things sometimes, my close friends understand most of the time. Acquaintances feel like I am a buzz kill". The veteran is not suicidal nor homicidal. Th vetera's mood is depressed daily nearly every day or all day, he describes difficult concentrating at home and at work."

Edited August 29, 2011 by brokensoldier244th

[john999]

It looks to me like a 30%-50% rating for MDD based on what was said in the C&P. 10% is too low and 70% is too high based just on your exam. My opinion.

[brokensoldier244th]

Its hard to tell, you know? The 30 and 50 percent ratings are similar in many ways, and the definitions of 'reduced reliability and productivity', 'disturbances of motivation and mood', and 'impairment of short and long term memory' could be construed any number of ways. He didn't ask about work absences or work directly, more about how I interacted at work. Maybe I should have taken in my write up for absences but since he didn't ask about it I didn't think of it. My treatment notes indicate instances where i have yelled at my kids for no reason, punched a hole in the wall while dragging their bed out of their room (since they wouldn't clean under it), snapped at people, and other such things. I would hope that those notes would be included as well.

Edited August 21, 2011 by brokensoldier244th

[Hoppy]

It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23)

My Axis(s) were listed as:

Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)<BR style="mso-special-character: line-break"><BR style="mso-special-character: line-break">

C&P examiners are experts at killing claims. It appears to me this examiner did everything possible to kill your claim. In researching your claim I wound up reading a current post you put on another website. After reading what you posted recently on hadit I see no connection between your depression and the service connected pain condition. The C&P is silent for a nexus between pain and depression. Correct me if I am wrong on this. If there is no link it would be a stretch for the rater to award the claim.

GO TO THIS LINK AND READ THIS DECISION

http://www.va.gov/vetapp11/Files1/1103562.txt

You will need a report similar to the one used to win the claim I told you to read at the BVA. Also, it appears your treating psychologist deferred making a link between your depression and service connected pain. This is a VA induced cop-out. She is following VHA directive 2008-71 ( see paragraph “D” below”. She is qualified to say yes or no, there is a link. However, the VHA told her she only needs to make statements addressing you current ability to function.

d. Medical Statements to Support VA Benefits Claims. When honoring requests for medical statements by veterans for VA claims adjudication, care must be taken to avoid conflict of interest or ambiguity.

(1) Determination of causality and disability ratings for VA benefits is exclusively a function of the Veterans Benefits Administration (VBA). VHA providers often do not have access to military medical records, and may not be familiar with all the health issues specific to military service, such as environmental exposure. As a result, they may not feel comfortable in stating causality of a current condition. However, this does not preclude VHA providers from recording any observations on the current medical status of the veteran found in the medical record,

including their current functional status. All pertinent medical records must be available for review by VBA. NOTE: VHA continues to provide compensation and pension (C&P) examinations and reports as requested by VBA, as part of any new disability claims or review process.

(2) Requests by a veteran for assistance in completing a VA disability claim are to be referred to VBA through official channels; however, the clinician, if requested by the veteran, must place a descriptive statement in the veteran’s medical record regarding the current status of the veteran’s existing medical condition, disease, or injury, including prognosis and degree of function. This may then be requested by VBA for the purposes of making a claim determination

[brokensoldier244th]

Interesting reading. Thanks for that.

I just called her and left a VM with that directive listed and I read the fun parts to the machine. Hopefully she will write up something. Id have to go look through all my treatment notes, but Im pretty sure my initial set of them she notes that Im there for depressions, pain and service connected lower back. In the first meeting notes under the diagnosis she notes that I will continue to come see her to address my depression and pain. i know that isn't a nexus, but I was hope for preponderance of evidence.

*shrug*

Thanks for looking at it a bit, Hoppy.

CAS

It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23)

My Axis(s) were listed as:

Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)<BR style="mso-special-character: line-break"><BR style="mso-special-character: line-break">

C&P examiners are experts at killing claims. It appears to me this examiner did everything possible to kill your claim. In researching your claim I wound up reading a current post you put on another website. After reading what you posted recently on hadit I see no connection between your depression and the service connected pain condition. The C&P is silent for a nexus between pain and depression. Correct me if I am wrong on this. If there is no link it would be a stretch for the rater to award the claim.

GO TO THIS LINK AND READ THIS DECISION

http://www.va.gov/vetapp11/Files1/1103562.txt

You will need a report similar to the one used to win the claim I told you to read at the BVA. Also, it appears your treating psychologist deferred making a link between your depression and service connected pain. This is a VA induced cop-out. She is following VHA directive 2008-71 ( see paragraph "D" below". She is qualified to say yes or no, there is a link. However, the VHA told her she only needs to make statements addressing you current ability to function.

d. Medical Statements to Support VA Benefits Claims. When honoring requests for medical statements by veterans for VA claims adjudication, care must be taken to avoid conflict of interest or ambiguity.

(1) Determination of causality and disability ratings for VA benefits is exclusively a function of the Veterans Benefits Administration (VBA). VHA providers often do not have access to military medical records, and may not be familiar with all the health issues specific to military service, such as environmental exposure. As a result, they may not feel comfortable in stating causality of a current condition. However, this does not preclude VHA providers from recording any observations on the current medical status of the veteran found in the medical record,

including their current functional status. All pertinent medical records must be available for review by VBA. NOTE: VHA continues to provide compensation and pension (C&P) examinations and reports as requested by VBA, as part of any new disability claims or review process.

(2) Requests by a veteran for assistance in completing a VA disability claim are to be referred to VBA through official channels; however, the clinician, if requested by the veteran, must place a descriptive statement in the veteran's medical record regarding the current status of the veteran's existing medical condition, disease, or injury, including prognosis and degree of function. This may then be requested by VBA for the purposes of making a claim determination

[Hoppy]

CAS

Read the directive carefully. It says they can comment on prognosis and degree of current disability. It says nothing about etiology or cause. You are seeking an opinion as to the cause of the depression. VA doctors are not required to address cause for the purpose of resolving a veteran’s claim. The directive tells the doctor to refer the veteran to proper channels. The proper channel’s according to the VBA is the C&P process.

I have tried to turn this around and asked the doctor if it would be beneficial for treatment to know the cause of the veteran’s depression. I get different answers to this question. I was told by one VA doctor that it does not matter for treatment to know the cause. The treatment is the same no matter what the cause. I am not sure this would be true in your case and if you are told this you should seek a second opinion from a qualified treating clinician. Due to the complications with VHA directive 2008-71 you might need to go outside the VA to get this resolved. Considering the opinion that was used in favor of the veteran’s claim I posted the link to, you should be able to get a similar opinion.

I take the BVA case to a clinician and tell them I need a report similar to the one that the BVA used to award the claim. As you can see from the case I linked this can get real complicated and drug out. The veteran in that case had to obtain opinions to rebut the C&P exam.

<BR clear=all> Eking an opinion

[brokensoldier244th]

If the VA heath providers are not supposed to opine on whether or not your depression (in this case) is a direct result of your SC issues, and the C&P examiners don't either, but the raters are looking for 'that statement', then what? Seems to be a sort of catch-22.

CAS

CAS

Read the directive carefully. It says they can comment on prognosis and degree of current disability. It says nothing about etiology or cause. You are seeking an opinion as to the cause of the depression. VA doctors are not required to address cause for the purpose of resolving a veteran's claim. The directive tells the doctor to refer the veteran to proper channels. The proper channel's according to the VBA is the C&P process.

I have tried to turn this around and asked the doctor if it would be beneficial for treatment to know the cause of the veteran's depression. I get different answers to this question. I was told by one VA doctor that it does not matter for treatment to know the cause. The treatment is the same no matter what the cause. I am not sure this would be true in your case and if you are told this you should seek a second opinion from a qualified treating clinician. Due to the complications with VHA directive 2008-71 you might need to go outside the VA to get this resolved. Considering the opinion that was used in favor of the veteran's claim I posted the link to, you should be able to get a similar opinion.

I take the BVA case to a clinician and tell them I need a report similar to the one that the BVA used to award the claim. As you can see from the case I linked this can get real complicated and drug out. The veteran in that case had to obtain opinions to rebut the C&P exam.

<BR clear=all> Eking an opinion