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Latest Compensation & Pension (C&P) Clinicians Guide as of 2020


marathonjon

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This is the latest Compensation & Pension (C&P) Clinicians Guide dated 20180719. The only other one I've seen is dated 2002, including the one on this website and the VA website. I got this from my claims agent, who got it from the VA.

VA Compensation & Pension (C&P) Clinicians Guide 2 Final Corrected 20180719.pdf

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20 hours ago, marathonjon said:

This is the latest Compensation & Pension (C&P) Clinicians Guide dated 20180719. The only other one I've seen is dated 2002, including the one on this website and the VA website. I got this from my claims agent, who got it from the VA.

VA Compensation & Pension (C&P) Clinicians Guide 2 Final Corrected 20180719.pdf 277.86 kB · 25 downloads

Thanks, needed that.

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20 hours ago, marathonjon said:

This is the latest Compensation & Pension (C&P) Clinicians Guide dated 20180719. The only other one I've seen is dated 2002, including the one on this website and the VA website. I got this from my claims agent, who got it from the VA.

VA Compensation & Pension (C&P) Clinicians Guide 2 Final Corrected 20180719.pdf 277.86 kB · 26 downloads

A quick scan tells me that the clinicians on the ground have different instructions. 

For example, I have a wrist injury.  The examiner's refuse to examine the metacarpal- carpal articulation of the thumb because only the metacarpal-carpal  articulation of the fingers is ordered by the RO.  Hearing loss claims do not include loss by tinnitus in examinations and the audiologist will not fill in the block for tinnitus even when requested most times even though it is reported to them during the audiogram as a problem for high frequency tones.

The Clinician's guide is compliant with 38 CFR 4.42 for injury examinations.  The injury examinations done at the VA are not.  Where do you find the instructions to the Rating Officer ordering the examination and the reason the examiners state they are not allowed to deviate from the specific ordered examination?

The links are to VBAW?  Will not produce?  The link to your document worked fine but there is no trail to see where it downloaded from?

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Not in the usual VA flourish publication.  But I recognize Marjorie Auer in the acknowledgements as the BVA Judge who rendered my May 11, 2017 BVA decision.

The 2002 version download in Word.  Doesn't appear to be as complete as the 2018 version.  This may be a work still in progress while we are not seeing what is actually going on with direct instructions and guidelines to the practitioners who are actually doing C&P examinations today.

And then it could be just look nice stuff to placate upset veterans.

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Lemuel, I'm not an expert on C&P exams, but I've been slogging through the M21-1, which addresses the exams in Part III, Subpart iv, Chapter 3. Section A of this chapter mentions several tools for inputting examination requests. I'm sure they are internal tools that are only accessible by the RO and the examiner. You can find this section here: https://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001018/content/554400000015809/M21-1,-Part-III,-Subpart-iv,-Chapter-3,-Section-A---Examination-Requests-Overview.

As I said, I got this version of the Clinician's Guide from my claims agent; all I know is she got it from the VA, I don't know anything about VBAW.

If you can't get the VA-appointed examiner to examine you properly and report it properly, then your only recourse is to get an independent medical examination and opinion. Unfortunately, they are not cheap, and it can be hard to find someone willing to do them. Beware of the ones who say they can do them by video; the VA does not accept these from private providers (even though they accept so-called telehealth exams from VA providers and contractors).

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I am not either.  But you have provided a step in the right direction.  ERRA doesn't get me to the point I want.  I want to know why 38 CFR 4.42 on injury examinations are not compliant as example in my wrist injury.  The VA avoided compensating me at 20% on the ankylosis of my thumb metacarpal to the wrist carpal bones by not including it in the exam and the physicians refusing to do the measurements on the thumb because it was not listed in the exam as though only fingers articulate with the wrist.  

Noise trauma is an injury to the hearing ability.  How many veterans know that if their tinnitus is not severe enough to drive them crazy that they have to note it separately as part of their hearing difficulty.  That using the words "hearing difficulty" or "hearing loss" is not enough.  They have to expand to say because of ringing in the ears.  It is not enough to do it on the first exam.  They have to know they have to come out of the exam and put in a claim for it separately from hearing loss or hearing difficulty.

How many multi-trauma victims don't get their full benefits because an RO limits the exam to narrow specifics not consistent with the below 38 CFR 4.42?  It is a subject of my unadjudicated 11/26/1994 Substantive Appeal in a next of friend filing for all affected.  As a HM1 in the Navy, I felt it was the least I could do.  Problem was that I had untreated temporal lobe epilepsy during those fighting years to that point and was unable to articulate my points all of the time or keep the VA straight.  Since 2015 I've been treated with Keppra for my TLE.  I'm back on track with most of my residual 126 Verbal IQ.  

38 CFR 4.42

"§4.42 Complete medical examination of injury cases.
The importance of complete medical examination of injury cases at the time of first medical examination by the Department of Veterans Affairs cannot be overemphasized. When possible, this should include complete neurological and psychiatric  examination, and other special examinations indicated by the physical condition, in addition to the required general and orthopedic or surgical examinations. When complete examinations are not conducted covering all systems of the body affected by disease or injury, it is impossible to visualize the nature and extent of the service connected disability. Incomplete
examination is a common cause of incorrect diagnosis, especially in the neurological and psychiatric fields, and frequently leaves the Department of Veterans Affairs in doubt as to the presence or absence of disabling conditions at the time of the examination."

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On 8/2/2020 at 12:01 PM, Lemuel said:

For example, I have a wrist injury.  The examiner's refuse to examine the metacarpal- carpal articulation of the thumb because only the metacarpal-carpal  articulation of the fingers is ordered by the RO.  Hearing loss claims do not include loss by tinnitus in examinations and the audiologist will not fill in the block for tinnitus even when requested most times even though it is reported to them during the audiogram as a problem for high frequency tones.

The Clinician's guide is compliant with 38 CFR 4.42 for injury examinations.  The injury examinations done at the VA are not.  Where do you find the instructions to the Rating Officer ordering the examination and the reason the examiners state they are not allowed to deviate from the specific ordered examination?

 

1) Is your wrist service-connected?  If it is, consider getting your own evaluation done.  My understanding is that some VA medical centers offer "DBQ clinics".  Get another doctor to fill one out.  Conflicting medical evidence is a solid basis for appeal.  If it's not service-connected, STILL get another evaluation of the severity of your condition.  Severity is separate from the medical opinion about nexus.  Try to make sure that any separate evaluation you get is in your record before the rating decision is issued.  

2) Examiners refusing to do something associated with the exam is unacceptable.  If they do that, document it on a VA Form 21-4138 and submit it BEFORE the examiner even submits the report to VA.  You can also call the contract vendor (QTC, VES, etc) and complain that the doctor refused to examine something.  Also, most DBQs are available publicly.  Get a copy and look at what they are supposed to be measuring/commenting on for that exam.  They can't refuse to do something that's on that DBQ (of course they can, but that's your basis for appeal). 

3) Unless your issue is on appeal and the exam was directed by a reviewer (rater or DRO), your exam is supposed to include EVERYTHING on that DBQ.  ROs don't order specialized exams that look at only SOME things on the DBQ.

4) Same as #1, but you can also tell the examiner that you'd like them to note what you said in their report.  Then YOU make a note of it.

5) "Rating Officer"s don't order exams except in very defined circumstances - as part of an appeal/review; or if the exam is deficient and they want it clarified or if there is conflicting evidence and they want a new examiner to reconcile the evidence.  Initially, exams are ordered by a VSR on the pre-development team and they are very generic requests.  We aren't usually personalizing an examination request (I've worked Pre-D) unless there is a reason i.e. verify a Veteran's stressor for PTSD, confirm a particular type of exposure.

6)  It's possible that the guidance attached in this thread says something about not deviating, but if the condition is related to the one we ordered an exam for, the examiner is REQUIRED to address it even if it means using additional DBQs to do so.  For instance, an exam for diabetes mellitus could also reveal diabetic neuropathy.  Those conditions would require 2 separate DBQs.  If we ordered the exam for diabetes and the examiner diagnoses diabetic neuropathy, they are required to do both DBQs.  Our contract vendors know how to bill VA for extra DBQs when the examiner says they are necessary.  It's possible that doctors aren't real clear on that process - I don't know.

Be your own advocate.  If you think the examiner is ignoring what you say, make your own record (or get a doctor to make one) and send it to VA ASAP.  The new appeals process can really work with that evidence.  Get it in your record.

Good luck,

Phury  

Edited by Phury & Rhage (see edit history)
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3 hours ago, Phury & Rhage said:

1) Is your wrist service-connected?  If it is, consider getting your own evaluation done.  My understanding is that some VA medical centers offer "DBQ clinics".  Get another doctor to fill one out.  Conflicting medical evidence is a solid basis for appeal.  If it's not service-connected, STILL get another evaluation of the severity of your condition.  Severity is separate from the medical opinion about nexus.  Try to make sure that any separate evaluation you get is in your record before the rating decision is issued.  

2) Examiners refusing to do something associated with the exam is unacceptable.  If they do that, document it on a VA Form 21-4138 and submit it BEFORE the examiner even submits the report to VA.  You can also call the contract vendor (QTC, VES, etc) and complain that the doctor refused to examine something.  Also, most DBQs are available publicly.  Get a copy and look at what they are supposed to be measuring/commenting on for that exam.  They can't refuse to do something that's on that DBQ (of course they can, but that's your basis for appeal). 

3) Unless your issue is on appeal and the exam was directed by a reviewer (rater or DRO), your exam is supposed to include EVERYTHING on that DBQ.  ROs don't order specialized exams that look at only SOME things on the DBQ.

4) Same as #1, but you can also tell the examiner that you'd like them to note what you said in their report.  Then YOU make a note of it.

5) "Rating Officer"s don't order exams except in very defined circumstances - as part of an appeal/review; or if the exam is deficient and they want it clarified or if there is conflicting evidence and they want a new examiner to reconcile the evidence.  Initially, exams are ordered by a VSR on the pre-development team and they are very generic requests.  We aren't usually personalizing an examination request (I've worked Pre-D) unless there is a reason i.e. verify a Veteran's stressor for PTSD, confirm a particular type of exposure.

6)  It's possible that the guidance attached in this thread says something about not deviating, but if the condition is related to the one we ordered an exam for, the examiner is REQUIRED to address it even if it means using additional DBQs to do so.  For instance, an exam for diabetes mellitus could also reveal diabetic neuropathy.  Those conditions would require 2 separate DBQs.  If we ordered the exam for diabetes and the examiner diagnoses diabetic neuropathy, they are required to do both DBQs.  Our contract vendors know how to bill VA for extra DBQs when the examiner says they are necessary.  It's possible that doctors aren't real clear on that process - I don't know.

Be your own advocate.  If you think the examiner is ignoring what you say, make your own record (or get a doctor to make one) and send it to VA ASAP.  The new appeals process can really work with that evidence.  Get it in your record.

Good luck,

Phury  

Phury,

Well into that.  Problem is doing face to face exams.  But going ahead, with an attorney,  in the appeal without additional examinations focusing on 38 CFR 4.42 injury examination requirements.  Trying to get the directives C&P examiners function under that seem to be non compliant with 4.42.  Really don't need an outside examiner.  Have the 1969 Naval Hospital, Oakland, CA surgery report from the IPTR.  Surgically fused bones don't become free of ankylosis.  They become more arthritic.  All that is needed is an orthopedic pathology text book.  (Thanks for the post.  Triggered a decision to do a thorough look up on the injury I have.  It is not all that uncommon.)

This has been a long standing minimalization effort by the military and VA since before the VA existed.  As an activist, I am trying to get C&P examinations to be compliant with the regulation.  We will see if the Court agrees once we get it there.  The Executive Director, Compensation Services, Beth Murphy may correct the situation before it gets there.

 

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On 8/1/2020 at 5:01 PM, marathonjon said:

This is the latest Compensation & Pension (C&P) Clinicians Guide dated 20180719. The only other one I've seen is dated 2002, including the one on this website and the VA website. I got this from my claims agent, who got it from the VA.

VA Compensation & Pension (C&P) Clinicians Guide 2 Final Corrected 20180719.pdf 277.86 kB · 754 downloads

your link doesn't work for me

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26 minutes ago, Tbird said:

your link doesn't work for me

It's not a link; it's an attachment to the forum post. When I click on it, Firefox asks me if I want to open it in Firefox or download it. Both options still work for me. Your popup or ad blocker may be preventing it from opening or downloading. As the site admin, you should be able to figure out what the issue is.

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On 8/1/2020 at 6:01 PM, marathonjon said:

This is the latest Compensation & Pension (C&P) Clinicians Guide dated 20180719. The only other one I've seen is dated 2002, including the one on this website and the VA website. I got this from my claims agent, who got it from the VA.

VA Compensation & Pension (C&P) Clinicians Guide 2 Final Corrected 20180719.pdf 277.86 kB · 782 downloads

Thank you for posting this! Solid info!

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