Casey Matuszak MOPH Training Orlando, FL March 2014

Transcription

1 Casey Matuszak

2 OBJECTIVE Overview of Several Fast Letters. o FL 12-22, FL 12-23, o FL 13-4, FL 13-5,, FL 13-9, FL o FL 13-13, FL 13-15, Discussion - Impact 2

3 FAST LETTER 13-15, July 9, 2013 SUBJ: Interim Procedures for Psychiatric Examinations Following the May 18, 2013, Release of the 5 th Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) 3

4 FAST LETTER Cont. VA examination requests must clearly state that examiners are to use the criteria in DSM-IV. The examiner must document that the diagnoses obtained were based on the criteria in DSM-IV. VHA clinicians state in treatment notes that criteria in DSM-IV used until transitioned to DSM-5. 4

5 FAST LETTER Cont. REV 11/27/13 VA will now accept diagnoses relatable to either historic DSM-IV or current DSM-5 criteria. VHA now performing examination using DSM-5 criteria, but that if no diagnosis is applicable under DSM-5, the examiner should provide a diagnosis and opinion, if applicable, under DSM-IV. If an exam report contains information utilizing both the DSM-IV and DSM-5, VA must use whichever evidence is more favorable to the Veteran. 5

6 FAST LETTER Cont. REV 11/27/13 VA not required to accept a mental disability DBQ that is otherwise inadequate for rating purposes. If VA determines that additional info required using DSM-IV criteria, VA will return exam as inadequate. Global Assessment of Functioning (GAF) score is not used in DSM-5 in diagnoses. World Health Organization Disability Assessment Schedule (WHODAS 2.0) 6

7 FAST LETTER 12-22, 10/3/12;Rev 8/27/13 SUBJ: Acceptable Clinical Evidence (ACE) VBA determines medical evidence of record is sufficient to rate. If not a DBQ is requested VHA may complete DBQ by reviewing medical evidence & possible telephone interview with the Vet. May alleviate an in-person exam. 7

8 FAST LETTER 12-22, 10/3/12;Rev 8/27/13 VHA can use ACE to complete DBQs o Assess the level of impairment. o Render a Medical Opinion as to whether disability incurred, aggravated in service o Render a Medical Opinion as to nexus o Render a Medical Opinion as to whether SC disability caused death 8

9 FAST LETTER 12-22, 10/3/12;Rev 8/27/13 VA will not exclude use of ACE for the following conditions, hearing loss tinnitus cardiac conditions amytrophic lateral sclerosis, and any terminal condition. 9

10 FAST LETTER 12-22, 10/3/12;Rev 8/27/13 VBA will not use ACE Pension claim BVA remand for an exam Disability at issue is a mental condition Predischarge claim A claim that involves electronic medical records not available to VHA 10

11 FAST LETTER 12-22, Cont. VHA Examiner must Note use of ACE, o IDs & details evidence material to finding(citing STRs, CPRS not sufficient), and o Documents rationale for reliance of ACE and not exam. If above not done DBQ returned as insufficient for rating purposes. 11

12 FAST LETTER 12-22, Cont. Non VHA C&P examiners can t use ACE VBA must send either claims folder or notice that an e-folder exists in Virtual VA or VBMS, as applicable, with every VHA compensation evaluation request. Why is VSO access to CAPRI important? 12

13 FAST LETTER,13-04, March 22, 2013 SUBJ: Simplified Processing of Dependency and Indemnity Compensation (DIC) Claims Screen for evidence of SC w/o file. If SC disability is principle/contributory cause of death grant DIC If cause of death is a presumptive and vet meets presumptive criteria, grant DIC. If vet rated P&T continuously for a disability/iu for 10/5/1 years prior to death grant DIC w/o development as to cause of death - 38 USC

14 FAST LETTER,13-04 Cont: Concede dependency when VA records as of the date of the Veteran's death establishes the survivor's relationship with the deceased Veteran Claimant entitled to DIC under 38 USC 1318 o Grant SC burial benefits o Grant DEA o Grant CHAMPVA 14

15 FAST LETTER 12-23, October 26, 2012 SUBJ: Room and Board as a Deductible Unreimbursed Medical Expense (UME) Cost of room & board at a residential facility is a UME if the facility provides custodial care (assists the individual with two or more ADLs), or the individual's physician states in writing that the claimant must reside in that facility to separately contract for custodial care with a third-party provider. 15

16 FAST LETTER Cont. If the facility does not provide custodial care, or claimant's physician does not prescribe care by a 3rd-party provider, VA won t deduct room & board but will consider UME cost of any medical/nursing services from a 3 rd party provider. NOTE: VA doesn t consider emergency pull cords, 24-hour staffing, and locked exterior doors as a medical or nursing service. 16

17 FAST LETTER Cont. As a general rule, charges for assistance with IADLs are not UMEs as such assistance is not a medical/nursing service but VA will consider them as UME s when: The individual is entitled to pension at the A&A or housebound rate, or physician has certified that the claimant has a need to be in a protected environment, AND The facility provides medical services or assistance with ADLs to the individual. 17

18 EXAMPLE: Last Rest Home assists their guest in bathing, dressing and eating. Tom vet goes in goes in there and gets help. Room and board is $2,000.00/month? Is room and board a UME? Pearly Gates Rest Home provides room and board. Cost is $2,000.00/month. Jim Vet goes there to live. Is room and board a UME? 18

19 EXAMPLE Pearly Gates Rest Home only provides room and board. Dan Vet goes there to live. Cost or rest home is $2,000.00/month. Six months later Dan s doctor says that he needs a CNA to help bathing, eating and dressing. Dan hires Judy at the rate of $ /month to do this. Is room and board a UME? Is Judy s salary a UME 19

20 EXAMPLE Pearly Gates Rest Home only provides room and board. Bob Vet goes there to live. Cost or rest home is $2,000.00/month. Six months later Bob decides he needs a CNA to help bathing, eating and dressing. Bob hires Norma Rae at the rate of $ /month to do this. Is room and board a UME? Is Norma Rae s salary a UME? 20

21 FAST LETTER 13-13, June 17, 2013 SUBJ: Claims for Total Disability Based on Individual Unemployability (IU) CHANGES: Claimant w/multiple disabilities, specify disability causing IU. Only disabilities specified claims for increase VA Form required Administrative denial if req. evidence not recd. 21

22 FAST LETTER 13-13, Cont: VA decides DBQ or general medical examination 38 C.F.R. 4.16(a) combined 70% rating is required if no single disability rated at 60%. Examiner not to opine whether or not the Vet s IU due to SC disabilities. o M21-1MR, III.iv.3.A.9.f. Rater is solely responsible for this decision. o Examiner only comment on the functional impairment caused solely by the SC disabilities. 22

23 FAST LETTER 13-10, MAY 20, 2013 SUBJ: Guidance on Date of Claim Issues Earliest date the information is received in any VA facility identified from the earliest VA date stamp. Exception use the date a previously unadjudicated claim is discovered not stamped date as date of claim for system control not as effective date of benefit. If incorrect date already established and an earlier date of claim is found, what date is used?. 23

24 FAST LETTER 13-09, April 25, 2013 SUBJ: Certification of Completeness of Service Treatment Records (STRs) Inform VARO of DOD s policy on certifying the completeness of paper service treatment records (STRs). Final medical treatment facility, including NG & Reserves, now certify the completeness of all paper STRs eliminating the need for unnecessary additional development. 24

25 FAST LETTER 13-09, Cont. Development for additional paper STRs should only be conducted when: o VET alleges treatment at a military treatment facility for a specific time frame and, o Treatment information not included in certified paper STRs. 25

26 FAST LETTER 13-05, March 26, 2013 SUBJ: Overview of Changes PL , 8/6/2012 Section 102. Hospital care/medical services for Vets & family stationed ( ) at Camp Lejeune. o TL 10-03, April 26, 2010, Environmental Hazards o FL January 11, 2011 Consolidation Camp Lejeune cases to Louisville RO 26

27 Section 203. Expansion of eligibility for SAH assistance for Veterans with vision impairment. o Expands eligibility for adaptive housing to Vets with a lesser degree of vision impairment than previously required. o Removes requirement that SC blindness in both eyes be permanently and totally disabling. o Minimum requirement - blindness in both eyes, having a central visual acuity of 20/200 or less in the better eye with use of a standard correcting lens. o Effective

28 FAST LETTER 13-05, March 26, 2013 SUBJ: Overview of Changes PL , 8/6/2012 Section 210. Waiver of loan fee for individuals with disability ratings issued during pre-discharge programs. Section 501. Automatic waiver of agency of original jurisdiction review of new evidence. Sec Filing jointly for SSA/DIC. o No specific form required rather interpret any document filed with either agency indicating intent to apply for survivor benefits as an application for benefits under both. Effective

29 FAST LETTER 13-05, Cont: Sec Use of electronic communication to provide VCAA Notices to claimants. Sec Reasonable efforts to assist claimants in obtaining private records. o VA will make not less than two requests for private records unless the first attempt reveals that further efforts would be futile. Sec Modification of month-of-death benefit for surviving spouses of vets who die while entitled to compensation or pension. 29

30 FAST LETTER 13-05, Cont: Sec Exclude the receipt of payments from insurance, court award, settlement, or other means for reimbursement of expenses caused by and incurred after an accident, theft, loss, or casualty loss, for the purposes of determining eligibility for pension. Sec Expansion of eligibility for presidential memorial certificates to persons who die in the active military, naval, or air service. 30

31 FAST LETTER 13-05, Cont: Sec VA can provide/assist with a 2 nd car/conveyance if the one VA previously provided is destroyed due to a natural or other disaster, no fault of vet, and vet not compensated by an insurer. Sec Requirement for plan for regular assessment of employees of Veterans Benefits Administration (VBA) who handle processing of claims for compensation and pension. 31

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