TBI C&P diagnosed Z87.820

[mrkman123]

C&P was done on 30 march 2016.  Does any one know what this means?    Examiner, concludes objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment.  Concludes, judgement mildly impaired for complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.  Concludes, social interaction is routinely appropriate.  Concludes orientation always oriented to person, time, place, and situation.  Concludes, motor activity is normal.  Concludes, visual spatial orientation is mildly impaired.  Concludes subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships.  Concludes, one or more neurobehavioral effects that interfere with workplace interaction or social interaction.  Concludes normal communication and comprehension and written language. Concludes residual subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI.  Concludes, mental disorder of ptsd, mdd, and tbi...  Moca test results, -1,-1,-2,-1.  Total Moca score; 25...  Normal range 26 or greater..   Diagnosis:  ICD code:  Z87.820.. Date of Diagnosis, 1991.     Can anyone figure this out?  

[Berta]

The MOCA test ( Montreal Cognitive Assessment test,) is for TBI assessments.

17 hours ago, mrkman123 said:

Concludes subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships.  Concludes, one or more neurobehavioral effects that interfere with workplace interaction or social interaction. 

That seems to be 2 statements that conflict with themselves. With a MOCA score one point less than normal they might give you only 10% or maybe even 0 %...it is very hard to determine from this brief part of the C & P and how the raters will view the quoted part above, as to subjective and neurobehavioral effects, as one does not seem to interfere with work (subjective)but the other neuro effects do.

And I am guessing as to the rating base on limited info here ....others will chime in as well.

I assume the inservice nexus to the TBI is not an issue.

Have you formally applied for PTSD due to the TBI or due to other stressors?

If so have you had a PTSD C & P exam yet?

Edited April 19, 2016 by Berta

[mrkman123]

Dear Ms. Berta,

Thank You for your reply and insight, I value Your skills of perception and understanding of the VA system.  The pdf files above are the C&Ps recently done at the Va outpatient center here in S. A..  The remand was from the BVA, addressing the issues and the need for the C&Ps' have been posted earlier this March.  I believe Your statement to the 15 pages remanded by the BVA was; " Looks like many steak and lobster dinners in the future", or something to that effect.  I wish I was better on the computer but, am forced to deal with learning all over again with a lot of daily issues...  The Nexus is not an issue, as the service medical records reflect the TBI, addressed as severe post concussion syndrome, with symptoms of depression and ptsd....  Applied for PTSD, Major depressive disorder, and TBI.. in 1992, and was denied of course.    Spent the last eight years at the VA being treated for the issues addressed in the remand, and the last three years the psychiatrist  has been trying to turn all of this into a personality disorder.  I know it is a hassle but, could you please readdress the remand and the C&Ps here for that data to help you further understand the claim and its peculiarities.  I would truly appreciate the assistance and will be always thankful for it.   Sincerely, Mark

[Berta]

I couldn't find the post where I said that.

Did you ever use a different handle (or name) posting here?

I sure must have seen something very positive to say that. If it was prior to 2005, the older hadit board is gone.