C&p Exam - "light Physical Employment" Translation?

[Punisher]

Hi All!

I've been sitting in the "Preparation for Decision" stage for almost two months now, so I'm doing lots of homework to be ready for any appeals or NODs.

One thing I cannot find anywhere is some documentation tying the statement below to where that would fall in the VA Schedule in the e-CFR page. The C&P VA Dr. put this throughout my shoulder, back, knee, wrist, etc., sections:

15. Functional impact

---------------------

Regardless of the Veteran's current employment status, do the condition(s)

listed in the Diagnosis Section impact his or her ability to perform any type

of occupational task (such as standing, walking, lifting, sitting, etc.)?

[X] Yes [ ] No

If yes, describe the impact of each of the Veteran's shoulder

conditions providing one or more examples:

LIGHT PHYSICAL EMPLOYMENT: SALES/TEACHING.

Does anyone know how that will determine the percentage in the e-CFR tables for the items I listed above?

Another question, based on the C&P Exam, she wrote Arthritis up separately from those problem areas above, but each of those addresses Arthritis as well. Does the VA award disability for BOTH Arthritis overall AND each of those items, or just take whatever is the highest %?

Thanks in advance!

[Punisher]

Took a while to clean it up and still takes up a lot of lines, but here is the section just for the shoulders:

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Shoulder and Arm Conditions

Disability Benefits Questionnaire

Name of patient/Veteran:

ACE and Evidence Review

-----------------------

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Indicate method used to obtain medical information to complete this document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because the existing medical evidence provided sufficient information

on which to prepare the DBQ and such an examination will likely

provide no additional relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using

the ACE process because the existing medical evidence supplemented

with a telephone interview provided sufficient information on which to

prepare the DBQ and such an examination would likely provide no

additional relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

a. Evidence review

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[X] Yes [ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in

the Veteran's VA claims file: CPRS AND VISTA WEB.

C-FILE REVIEWED PER VBMS AND VIRTUAL VA.

ALL ROM FOR THIS EXAM WAS COMPLETED WITH THE USE OF A GONIOMETER.

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [X] No

1. Diagnosis

------------

a. List the claimed condition(s) that pertain to this DBQ:

BILATERAL SHOULDER CONDITION

b. Select diagnoses associated with the claimed condition(s) (check all that

apply):

[X] Rotator cuff tendonitis

Side affected: [ ] Right [X] Left [ ] Both

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ICD Code: 840.9

Date of diagnosis: Left 2014

[X] Other (specify):

Other diagnosis: rt shoulder: labral tear and DJD of the AC joint

Side affected: Right

ICD code: 840.9

Date of diagnosis (right side): 9/2005

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c. Comments, if any:

No response provided

d. Was an opinion requested about this condition?

[ ] Yes [X] No [ ] N/A

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

shoulder or arm condition (brief summary):

Veteran with a hx of bilateral shoulder complaints, left greater than rt.

LEFT SHOULDER: He gives a hx of left shoulder pain since the Fall of 2013.

This occured while he was on a deployment and was doing pulls ups. Has had

chronic pain ever since. Was seen and evaluated and underwent an MRI of

the left shoulder later that documented rotator cuff tendonitis. Pain has

since continues. Pain is daily and can last from hours to the entire day.

Always brought on by overhead work. Pain ranges from a 2-7/10. No hx of any

left shoulder injections. Increased pain with increased activity.

RIGHT SHOULDER: Veteran a hx of rt shoulder pain since 2004. This occured

during a softball game. He collided with another player and injured the rt

shoulder at that time. Pain has continued ever since. He completed an MRI

of the rt shoulder in 2005. He was sent to PT for this condition. Pain at

this time occurs daily and will range from 1 hour to all day with a pain

scale of 1-7/10. Increased pain with activity. Per review of medical

records, He completed an MRI of the rt shoulder in 2005 that documented a

labral tear along with DJD of the rt shoulder.

current tx: naproxen 500mg po twice per day as needed/or motrin prn,

topical analgesia prn.

NO surgical hx.

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In regards to additional per cent loss of motion during rep movement, this

examiner is not able to accurately determine additional loss of motion

without resorting to mere speculation. Examiner is unable to determine

any measurable objective evidence to determine additional loss of motion

during rep movement. No flares.

b. Dominant hand:

[X] Right [ ] Left [ ] Ambidextrous

c. Does the Veteran report flare-ups of the shoulder or arm?

[ ] Yes [X] No

d. Does the Veteran report having any functional loss or functional

impairment of the joint or extremity being evaluated on this DBQ (regardless of

repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional loss or

functional impairment in his or her own words:

NO weights, pull ups. NO contact sports. Avoids overhead work.

3. Range of motion (ROM) and functional limitation

--------------------------------------------------

a. Initial range of motion

Right Shoulder

--------------

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Flexion (0 to 180): 0 to 175 degrees

Abduction (0 to 180): 0 to 150 degrees

External rotation (0 to 90): 0 to 90 degrees

Internal rotation (0 to 90): 0 to 90 degrees

If ROM is outside of normal range, but is normal for the Veteran (for

reasons other than a shoulder condition, such as age, body habitus,

neurologic disease), please describe:

n/a

If abnormal, does the range of motion itself contribute to functional loss?

[X] Yes (please explain) [ ] No

If yes, please explain:

limited overrhead work

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Description of pain (select best response):

Pain noted on exam and causes functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Flexion, Abduction, External rotation, Internal rotation

Is there evidence of pain with weight bearing? [X] Yes [ ] No

Is there objective evidence of localized tenderness or pain on palpation of

the joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

pain diffuse

Is there objective evidence of crepitus? [ ] Yes [X] No

Left Shoulder

-------------

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Flexion (0 to 180): 0 to 165 degrees

Abduction (0 to 180): 0 to 155 degrees

External rotation (0 to 90): 0 to 90 degrees

Internal rotation (0 to 90): 0 to 90 degrees

If ROM is outside of normal range, but is normal for the Veteran (for

reasons other than a shoulder condition, such as age, body habitus,

neurologic disease), please describe:

n/a

If abnormal, does the range of motion itself contribute to functional

loss? [X] Yes (please explain) [ ] No

If yes, please explain:

limited overhead work

Description of pain (select best response):

Pain noted on exam and causes functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Flexion, Abduction, External rotation, Internal rotation

Is there evidence of pain with weight bearing? [X] Yes [ ] No

Is there objective evidence of localized tenderness or pain on palpation of

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the joint or associated soft tissue? [X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s): diffuse but most sig over the supraspinatus tendon.

Is there objective evidence of crepitus? [ ] Yes [X] No

b. Observed repetitive use

Right Shoulder

--------------

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional functional loss or range of motion after three

repetitions? [ ] Yes [X] No

Left Shoulder

-------------

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional functional loss or range of motion after three

repetitions? [ ] Yes [X] No

c. Repeated use over time

Right Shoulder

--------------

Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

In regards to additional per cent loss of motion during rep movement,

this examiner is not able to accurately determine additional loss of

motion without resorting to mere speculation. Examiner is unable to

determine any measurable objective evidence to determine additional

loss of motion during rep movement. No flares.

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Left Shoulder

-------------

Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

In regards to additional per cent loss of motion during rep movement,

this examiner is not able to accurately determine additional loss of

motion without resorting to mere speculation. Examiner is unable to

determine any measurable objective evidence to determine additional

loss of motion during rep movement. No flares.

d. Flare-ups: No response provided

e. Additional factors contributing to disability

Right Shoulder

--------------

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None

Left Shoulder

-------------

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None

4. Muscle strength testing

--------------------------

a. Muscle strength - Rate strength according to the following scale:

0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement

2/5 Active movement with gravity eliminated

3/5 Active movement against gravity

4/5 Active movement against some resistance

5/5 Normal strength

Right Shoulder: Rate Strength:

Forward flexion: 5/5

Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

Left Shoulder: Rate Strength:

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Forward flexion: 5/5

Abduction: 5/5

Is there a reduction in muscle strength? [ ] Yes [X] No

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

c. Comments, if any:

No response provided

5. Ankylosis

------------

Complete this section if the Veteran has ankylosis of scapulohumeral

(glenohumeral) articulation (shoulder joint) (i.e., the scapula and humerus

move as one piece).

a. Indicate severity of ankylosis and side affected (check all that apply):

Right side:

[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head

(Favorable ankylosis)

[ ] Ankylosis in abduction between favorable and unfavorable

(Intermediate ankylosis)

[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable

ankylosis)

[X] No ankylosis

Left side:

[ ] Ankylosis in abduction up to 60 degrees; can reach mouth and head

(Favorable ankylosis)

[ ] Ankylosis in abduction between favorable and unfavorable

(Intermediate ankylosis)

[ ] Ankylosis in abduction at 25 degrees or less from side (Unfavorable

ankylosis)

[X] No ankylosis

b. Comments, if any:

No response provided

6. Rotator cuff conditions

--------------------------

Is rotator cuff condition suspected?

Right Shoulder: [X] Yes [ ] No

If "Yes" complete the following:

Hawkins' Impingement Test (Forward flex the arm to 90 degrees with

the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation

indicates a positive test; may signify rotator cuff tendinopathy or tear.)

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[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees.

Patient turns thumbs down and resists downward force applied by the

examiner. Weakness indicates a positive test; may indicate rotator cuff

pathology, including supraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

External Rotation/ Infraspinatus Strength Test (Patient holds arms at

side with elbow flexed 90 degrees. Patient externally rotates against

resistance. Weakness indicates a positive test; may be associated with

infraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Lift-off Subscapularis Test (Patient internally rotates arm behind lower

back, pushes against examiner's hand. Weakness indicates a positive

test; may indicate subscapularis tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Left Shoulder: [X] Yes [ ] No

If "Yes" complete the following:

Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the

elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation

indicates a positive test; may signify rotator cuff tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Empty-can Test (Abduct arm to 90 degrees and forward flex 30 degrees.

Patient turns thumbs down and resists downward force applied by the

examiner. Weakness indicates a positive test; may indicate rotator cuff

pathology, including supraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

External Rotation/ Infraspinatus Strength Test (Patient holds arms at

side with elbow flexed 90 degrees. Patient externally rotates against

resistance. Weakness indicates a positive test; may be associated with

infraspinatus tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

Lift-off Subscapularis Test (Patient internally rotates arm behind lower

back, pushes against examiner's hand. Weakness indicates a positive

test; may indicate subscapularis tendinopathy or tear.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

7. Shoulder instability, dislocation or labral pathology

--------------------------------------------------------

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a. Is shoulder instability, dislocation or labral pathology suspected?

[X] Yes [ ] No

If yes, complete questions 7b - 7d below:

b. Is there a history of mechanical symptoms (clicking, catching, etc.)?

[ ] Yes [X] No

c. Is there a history of recurrent dislocation (subluxation) of the

glenohumeral (scapulohumeral) joint?

[ ] Yes [X] No

d. Crank apprehension and relocation test (with patient supine, abduct

patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense

of instability with further external rotation may indicate shoulder instability.)

[X] Positive [ ] Negative [ ] Unable to perform [ ] N/A

If positive, indicate side affected: [X] Right [ ] Left [ ] Both

8. Clavicle, scapula, acromioclavicular (AC) joint and sternoclavicular joint

conditions

------------------------------------------------------------------------------

a. Is a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular

joint condition suspected?

[X] Yes [ ] No

If yes, complete questions 8b, 8d and 8e below:

b. Does the Veteran have an AC joint condition or any other impairment of the

clavicle or scapula?

[X] Yes [ ] No

If yes, indicate severity and side affected, and answer 8c below:

[X] Other, describe: DJD ON MRI SCAN FROM 9/2005 AT THE AC JOINT

[X] Right [ ] Left [ ] Both

c. Does the clavicle or scapula condition affect range of motion of the

shoulder (glenohumeral) joint?

[ ] Yes [X] No

d. Is there tenderness on palpation of the AC joint?

[ ] Yes [X] No

e. Cross-body adduction test (Passively adduct arm across the patient's body

toward the contralateral shoulder. Pain may indicate acromioclavicular

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joint pathology.)

[ ] Positive [X] Negative [ ] Unable to perform [ ] N/A

9. Conditions or impairments of the humerus

-------------------------------------------

a. Does the Veteran have loss of head (flail shoulder), nonunion (false flail

shoulder), or fibrous union of the humerus?

[ ] Yes [X] No

b. Does the Veteran have malunion of the humerus with moderate or marked

deformity?

[ ] Yes [X] No

c. Does the humerus condition affect range of motion of the shoulder

(glenohumeral) joint?

No response provided

d. Comments, if any:

No response provided

10. Surgical procedures

-----------------------

No response provided

11. Other pertinent physical findings, complications, conditions, signs,

symptoms and scars

------------------------------------------------------------------------

a. Does the Veteran have any other pertinent physical findings, complications,

conditions, signs or symptoms related to any conditions listed in the

Diagnosis Section above?

[ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

Section above?

[ ] Yes [X] No

c. Comments, if any:

No response provided

12. Assistive devices

---------------------

No response provided

13. Remaining effective function of the extremities

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Due to the Veteran's shoulder and/or arm conditions, is there functional

impairment of an extremity such that no effective function remains other than

that which would be equally well served by an amputation with prosthesis?

(Functions of the upper extremity include grasping, manipulation, etc., while

functions for the lower extremity include balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

14. Diagnostic testing

----------------------

a. Have imaging studies of the shoulder been performed and are the results

available?

[X] Yes [ ] No

If yes, is degenerative or traumatic arthritis documented?

[X] Yes [ ] No

If yes, indicate shoulder: [X] Right [ ] Left [ ] Both

b. Are there any other significant diagnostic test findings or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief

summary):

Exam Date/Time:

12/04/2014 14:28

Procedure Name:

MRI SHOULDER LT W/O CONTRAST

Reason for Study:

Clinical History:

Impression:

Report:

MRI SHOULDER LT W/O CONTRAST

Exm Date: 12/04/2014 14:28

Req Phys: Pat Loc:

Img Loc: MEDICAL GROUP

Service:

Exam: 14033464 MRI SHOULDER LT W/O CONTRAST CPT: MRI,JOINT,UP

EXTRM;WO CONT MAT

Report Status: VERIFIED Date Verified: 12/05/2014 09:00

Page 62 of 150

Report:

Reason for Order:

Please evaluate for RTC dysfunciton of possible supraspinatus

pain and subscapularis as well as labrum dysfunction of the left

shoulder. Pain continues and xray showed possible RTC impingement due

to subacromial space narrowing.

Order Comment:

REPORT:

RESCODE'S REPORT

MRI left shoulder: There are plain films available for correlation dated 4/28/14.

Technique: Multiplanar, multisequence images of the left shoulder

are provided without contrast utilizing routine protocol.

Findings:

There is severe acromioclavicular arthrosis. This focally depresses the

supraspinatus myotendinous junction. The supraspinatus tendon is

heterogeneous, compatible with tendinosis. There is a small amount

of subacromial bursal fluid. There is no focal fluid signal in the

supraspinatus or infraspinatus tendons to suggest tear. The subscapularis tendon

is intact and signal is unremarkable. The biceps tendon is anatomically positioned in

the bicipital groove. At the level of the biceps anchor, there is mild biceps

tendon signal heterogeneity, compatible with biceps tendinosis.

Superior labral morphology is grossly unremarkable. No intrinsic signal

abnormalities to suggest superior labral tear are appreciated. Labral

morphology anteriorly

Page 63 of 150

and anteroinferiorly is unremarkable with no intrinsic foci of fluid signal to

suggest labral tear. There is a small focus of fluid signal in the posterior

labrum that extends from mid glenoid level to the inferior quadrant, and is

suspicious for a posterior labral tear. Recommend clinical correlation for

signs of posterior instability. Anterior and posterior bands of the inferior

glenohumeral ligament are grossly unremarkable.

Impression:

Stigmata of rotator cuff impingement with supraspinatus tendinosis. No

definite evidence for a supraspinatus tear. A chronic tear could be obscured

by scar tissue but there is no significant subacromial subdeltoid bursal fluid.

Possible labral tear, posterior inferior quadrant, as above.

Biceps tendinosis.

Date Transcribed: 12/05/2014 09:00

Primary Intrepreting Staff:

Primary Interpreting Assistant:

Technologist:

Facility:

MEDICAL GROUP

********************

Exam Date/Time:

11/07/2014 07:28

Procedure Name:

SHOULDER, RT (4V, IMPINGEMENT SERIES)

Reason for Study:

Clinical History:

Impression:

Report:

SHOULDER, RT (4V, IMPINGEMENT SERIES)

Page 64 of 150

Exm Date: 11/07/2014 07:28

Req Phys: 64969 Pat Loc:

Img Loc: Medical Group

Service:

Exam: 14033468 SHOULDER, RT (4V, IMPINGEMENT SERIES) CPT:

SHOULDER, RT (4V, IMPINGEMENT SERIES)

Report Status: Complete Date Verified: 11/07/2014 09:08

Report:

Reason for Order:

Continued pain and weakness with pain in the supraspinatus and

with apprehension test. May have RTC dysfunction. Please evaluate

Order Comment:

REPORT:

SEE RADIOLOGIST'S REPORT

4 views of the right shoulder were obtained.

Findings: There is no acute fracture or malalignment.

The acromioclavicular and glenohumeral joints are normal.

The bone mineralization is normal.

Impression: Normal right shoulder.

Date Transcribed: 10/27/2014 16:05

Facility:

MEDICAL GROUP

************

MRI of the rt shoulder dated 9/25/2005: labral tear and also DJD at the

AC joint.

c. If any test results are other than normal, indicate relationship of

abnormal findings to diagnosed conditions:

N/A

Page 65 of 150

15. Functional impact

---------------------

Regardless of the Veteran's current employment status, do the

condition(s) listed in the Diagnosis Section impact his or her ability to perform

any type of occupational task (such as standing, walking, lifting, sitting, etc.)?

[X] Yes [ ] No

If yes, describe the impact of each of the Veteran's shoulder conditions

providing one or more examples:

LIGHT PHYSICAL EMPLOYMENT: SALES/TEACHING.

16. Remarks, if any:

--------------------

No remarks provided

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