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Incapacitating episodes

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bigoc

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Interested in C&P experiences with incapacitating episodes.  

I had a C&P for an increase of psoriatic arthritis of the hands and feet.  The examiner asked if I had missed any work due to my condition.  I responded yes to 5 days in the last 6 months.  The examiner set the time frame of the question.  He did not inquire further if it was bed rest ordered by a doctor.  I have learned not to interrupt this doc when he is documenting.  I basically spend 1 1/2 to 2 hours with this guy and talk about 5 minutes of the time a most.  I have been surprised by this guy in the past in a positive way.  He is kinda rude but tends to give me favorable exams that are used for favorable decisions.  I could care less about his attitude since the exam is helpful for my claim.  I wonder how common this is to have a rude examiner that give favorable exams that are basically inferred and not confirmed.  Meaning he just puts things down that I did not necessarily say but could be interpreted.     

My question is, is this a way examiners document incapacitating episodes?

I understand it seems a little short of meeting the criteria. I also know the examiners sometimes do their own thing.  Will this possibly be accepted by the RO as incapacitating episodes?

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Bigoc, I once had a doctor with a beside manner that was terrible but he wrote my disability letter.  I find this common with neurologists, lousy bedside manner.  If he helps and is willing to go to bat for you do not find another.  Having a doctor that is willing to go to bat for you against the VA is a good thing and you might not find another.

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  • Content Curator/HadIt.com Elder

The criteria for "incapacitating episodes" appears to generally be bed rest and treatment by a physician. There are a number of disabilities where incapacitating episodes are part of the rating criteria. Examples include arthritis, eye, sinusitis, respiratory, digestive, liver, eating disorders, etc... I posted a few of these below, but you can always search all the rating criteria yourself at this link:

https://www.ecfr.gov/cgi-bin/text-idx?SID=9e535d8495e409025d1c7817db9e762c&mc=true&node=pt38.1.4&rgn=div5

The easiest way to prove this would be to use your medical records.

Quote
6514   Sinusitis, sphenoid, chronic.  
General Rating Formula for Sinusitis (DC's 6510 through 6514):  
Following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries 50
Three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting 30
One or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting 10
Detected by X-ray only 0
Note: An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician.

 

Quote

 

6601   Bronchiectasis:  
With incapacitating episodes of infection of at least six weeks total duration per year 100
With incapacitating episodes of infection of four to six weeks total duration per year, or; near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously 60
With incapacitating episodes of infection of two to four weeks total duration per year, or; daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year 30
Intermittent productive cough with acute infection requiring a course of antibiotics at least twice a year 10
Or rate according to pulmonary impairment as for chronic bronchitis (DC 6600).  
Note: An incapacitating episode is one that requires bedrest and treatment by a physician.

 

Quote
Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes  
With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months 60
With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months 40
With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months 20
With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months 10
Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.  
Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment.

 

 

 

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It was not doctor ordered bedrest.  The C&P examiner was the one that asked how many days in the last 6 months I had missed work.  I am wondering why the C&P examiner would ask this?

I don't find anything in the 5002 active process arthritis rating criteria that uses this question.  Perhaps this is what some examiners are RO use to establish incapacitating episodes.

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  • Content Curator/HadIt.com Elder
On 10/18/2019 at 7:36 PM, bigoc said:

It was not doctor ordered bedrest.  The C&P examiner was the one that asked how many days in the last 6 months I had missed work.  I am wondering why the C&P examiner would ask this?

I don't find anything in the 5002 active process arthritis rating criteria that uses this question.  Perhaps this is what some examiners are RO use to establish incapacitating episodes.

This link should give you some insight into why they ask certain questions: https://www.benefits.va.gov/compensation/dbq_disabilityexams.asp

The C&P doc fills out a disability questionnaire. They probably asked the question about the episodes because it is on the form. Those forms also cover a lot of issues and have numerous subsections for varying maladies.

Remember that 5002 active arthiritis is only part of the problem. They probably were doing a spine assessment, which is common because arthritis leads to joint issues which can lead to pain, incapacitating episodes, etc...

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I know this is old, but I keep seeing this misunderstanding, and the definition applied incorrectly to 5002.

"Did the doctor order bed rest?"

Under 5002, bed rest would be contraindicated for inflammatory arthritis such as PSA and RA, as activity is the usual recommendation to prevent a joint from locking up.  Bed rest would only make it worse.  For the purposes of 5002, there is no set definition but it usually means that the patient isn't able to do what he/she normally can do as a result of the inflammatory arthritis or required time off work to see doctors.  I get to work all the time with joint pain and stiffness because if I give in and stay home and lay around it only makes it worse.  Being unable to get up and clean the house or unable to do social activities because one is in so much pain and has fatigue is a good example of a totally incapacitating episode.  Having to take time off work to go to the doctor for followups and blood tests because one is on multiple drugs to try to slow or halt the disease process would be a totally incapacitating episode, because the person is unable to earn income like a normal person does because they have to take off work to go to the VA doc.

Edited by jonnyohio
fixed spelling
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