Department of Veterans Affairs M21-1, Part III, Subpart IV



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2. Examination Report Requirements

Introduction

This topic contains information about reviewing examination reports, including


  • who must sign examination reports

  • ensuring examiners are qualified

  • telehealth examinations

  • Disability Benefits Questionnaires (DBQs) completed by VA or non-VA health care providers

  • DBQs completed by Veterans who are physicians/health care providers

  • qualification requirements of examiners – initial mental disorder examinations

  • qualification requirements of examiners – review or increased evaluation mental disorder examinations

  • qualification requirements of examiners – Traumatic Brain Injury (TBI) examinations

  • qualification requirements of examiners – hearing loss and tinnitus

  • requirements for examination reports

  • requirements for Acceptable Clinical Evidence (ACE) examination reports

  • evaluating disability diagnoses

  • questions about competency and/or validity of examinations

  • handling unusual cases

  • accepting a fee-based examiner’s report, and

  • examiner statements that an opinion would be speculative.



Change Date

July 22, 2015September 24, 2015



a. Who Must Sign Examination Reports

All examination reports must be signed by the examining health care provider.
Note: Examination reports transmitted electronically by either the VA medical center or by a contract examination provider must be digitally-signed.



b. Ensuring Examiners Are Qualified

VA medical facilities (or the medical examination contractor) are responsible for ensuring that examiners are adequately qualified.
Veterans Service Center (VSC) employees are not expected to routinely review the credentials of clinical personnel to determine the acceptability of their reports, unless there is contradictory evidence of record.
The examination provider's certification and signature block on the Disability Benefits Questionnaire (DBQ) or examination report received from a health care provider must contain the following


Notes:

  • The specialty of the exam provider must be indicated, if a specialist examination is required or requested, as in TBI examinations.

  • The SIGNATURE BLOCK should contain a legible signature and examiner’s credentials.

  • Health care providers participating in the Clinicians in Residence program at ROs must be registered and certified VHA clinicians.


References: For more information on

DBQs completed by VA or Non-VA health care providers, see M21-1, Part III, Subpart iv, 3.D.2.d, and

requirements for DBQ providers, see M21-1, Part III, Subpart iv, 3.A.3.e.




c. Telehealth Examinations

When VHA elects to conduct a videoconference examination (telehealth examination) in lieu of an in-person examination, the Rating Veteran Service Representative (RVSR) or Decision Review Officer (DRO) must assess the report for sufficiency under the same standards applicable to in-person examinations.
Reference: For more information on telehealth examinations, see the Office of Disability and Medical Assessment (DMA) Expansion of Telehealth for Compensation and Pension (C&P) Examinations Fact Sheet.



d. DBQs Completed by VA or Non-VA Health Care Providers

Review DBQs which are completed by VA or non-VA health care providers to ensure


  • the health care provider meets any specialty requirement for the examination conducted, and

  • the DBQ is sufficient for rating purposes.

If a Veteran submits a DBQ completed by a health care provider and it is insufficient for rating purposes, then the RVSR will determine if




  • development is required to the health care provider (such as validation of results by the treatment provider, obtaining medical records), or

  • an additional VA examination or medical opinion is to be requested.


Notes:

  • If a Veteran submits a DBQ which is not approved for public use, review the report to determine if it is sufficient for rating purposes. If additional examination requirements are needed such as an Service Treatment Records (STRs) review, then ask a VA examiner to perform only those missing requirements.

  • DBQs completed by a licensed health care provider, to include a nurse practitioner or physician’s assistant, are acceptable for VA examinations.


References: For more information on

  • DBQs approved for public use, see DBQ Switchboard

  • requirements for examination reports, see M21-1, Part III, Subpart iv, 3.D.2.j

  • use and acceptance of DBQs for VA examinations and opinions, see M21-1, Part III, Subpart iv, 3.A.3.b

  • specialty requirements for mental examination providers, see M21-1, Part III, Subpart iv, 3.D.2.f and g

  • specialty requirements for traumatic brain injury (TBI) examinations, see M21-1, Part III, Subpart iv, 3.D.2.h, and

  • specialty requirements for audiology examinations, see M21-1, Part III, Subpart iv, 3.D.2.i.



e. DBQs Completed by Veterans Who are Physicians/Health Care Providers

VA cannot summarily discount otherwise competent medical evidence from a Veteran who is a physician or health care provider. The DBQ reports completed by these individuals will be reviewed under the same criteria for reviewing DBQs submitted by a health care provider.
In effect, VA claims adjudicators must subject the evidence of record to some degree of scrutiny to determine its probative worth. It is improper in VA practice to “exclude” evidence. Decision makers must weigh the; its probative value is to be weighedof the evidence, and discuss its probative value in the reasons and basesdecision narrative for the assessment of its probative value clearly articulated.
Note: Exercise the same weighing of probative value for internal-use DBQs that are completed by an external non-VA provider.

Important: Ensure the Disability Benefits Questionnaire (DBQ) – Veteran Provided DOCUMENT TYPE under VBMS UNSOLICITED EVIDENCE tab has been updated for DBQs submitted from non-VA providers.
References: For more information on

  • reviewing DBQs completed by health care providers, see M21-1, Part III, Subpart iv,3.D.2.d

  • evidentiary concepts, see M21-1, Part III, Subpart iv, 5.2

  • competent medical evidence, see

  • 38 CRF 3.159(a)(1), and

  • M21-1, Part III, Subpart iv, 5.2.c

  • written testimony submitted by the claimant, see 38 CFR 3.200(b), and

  • case law supporting adequacy of examination completed by a Veteran-health care provider, see

  • Pond v. West, 12 Vet. App. 341 (1999) and,

  • Pellerin v. Derwinski, 2 Vet.App. 450 (1992).


f. Qualification Requirements of Examiners – Initial Mental Disorder Examinations

Mental health professionals with the following credentials are qualified to perform initial compensation and pension (C&P) mental disorder examinations
board-certified or board-eligible psychiatrists

licensed doctorate-level psychologists, or

the following other mental health professionals, under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist

doctorate-level mental health providers

psychiatry residents, or

clinical or counseling psychologists completing a one-year internship or residency.


Note: “Close supervision” means that the supervising psychiatrist or psychologist met with the Veteran and conferred with the examining mental health professional in providing the diagnosis and the final assessment. The supervising psychiatrist or psychologist must co-sign the examination report.
Important: For a claim for posttraumatic stress disorder (PTSD) based upon a stressor related to the Veteran’s fear of hostile military or terrorist activity, 38 CFR 3.304(f)(3) directs that the examination must be conducted by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted.
Reference: For more information on the qualifications of examiners for specific examinations, to include initial mental disorders examinations, PTSD, and eating disorders, see the DBQ Switchboard.



g. Qualification Requirements of Examiners – Review or Increased Evaluation Mental Disorder Examinations

Mental health professionals with the following credentials are qualified to perform C&P mental disorder review examinations or examinations in claims for increased evaluations of service-connected (SC) mental disorders
mental health professionals qualified to perform initial mental disorder examinations per M21-1, Part III, Subpart iv, 3.D.1.f, or

other mental health professional under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist, including

licensed clinical social workers

nurse practitioners

clinical nurse specialists, and

physician assistants.


Reference: For more information on the qualifications of examiners for review examinations for PTSD, see the PTSD DBQ in the DBQ Switchboard.



h. Qualification Requirements of Examiners - TBI Examinations

The initial diagnosis of traumatic brain injury (TBI) must be made by one of the following specialists
physiatrists,

psychiatrists,

neurosurgeons, or

neurologists.



Note: A generalist clinician who has successfully completed the Disability Examination Management Office (DEMO) TBI training module may conduct a TBI examination, if a TBI diagnosis is of record and was established by one of the aforementioned specialty providers.
Reference: For more information on qualifications of examiners for TBI examinations, see the TBI DBQ in the DBQ Switchboard.



i. Qualification Requirements of Examiners – Hearing Loss and Tinnitus

Hearing loss examinations must be completed by an audiologist. A hearing loss examination is needed for an initial exam for tinnitus.
If only a tinnitus examination is being requested, the examination may be conducted by either an audiologist or non-audiologist clinician, if a hearing loss examination is of record.
References: For more information on

  • qualifications for examiners for hearing loss and tinnitus examinations, see the Hearing Loss and Tinnitus DBQ in the DBQ Switchboard

  • evaluating hearing loss and tinnitus, see

  • 38 CFR 4.85, and

  • M21-1, Part III, Subpart iv, 4.B.3.



j. Requirements for Examination Reports

VA examinations are to be conducted using DBQs which are disease and condition-specific, organized as a documentation tool to provide the precise medical evidence needed to rate specific disabilities. The examiner is


  • asked to complete the form step by step

  • answer the questions posed, and

  • provide additional information as required by examination findings.


Note: The report must have a definite and unambiguous description of the disability for each complaint or claimed condition.
Common features of DBQs include


  • a diagnosis section

  • medical history

  • objective findings

  • results of diagnostic testing performed, and

  • a remarks section for any necessary explanation.

Additional sections may be found on some DBQs, depending on the specialty involved.


Reference: For more information on DBQs, see the DBQ Switchboard.



k. Requirements for ACE Examination Reports

When VHA uses Acceptable Clinical Evidence (ACE) in lieu of conducting an in-person examination, the RVSR or DRO must review the report for sufficiency. The report must


  • note use of the ACE process

  • clearly identify the specific evidence material to the report findings or opinion, with as much detail as necessary, and

  • document the rationale for relying on ACE rather than an in-person examination.


Reference: For more information on ACE exams, see M21-1, Part III, Subpart iv, 3.A.4.



l. Evaluating Disability Diagnoses

The precise cause of a disability is often difficult to determine. It is important that

the same disability is not covered by more than one diagnosis, and



a definite and unambiguous diagnosis is made for each complaint or symptom having a medical cause.
The table below describes various examination scenarios and what is required for a sufficient diagnosis.




If ...

Then ...

there are no findings on examination

a diagnosis of a disability should not be rendered by the examiner.
Example: Examiner states “normal left knee” and examination shows normal range of motion (ROM), normal stability, and no complaints of pain or other symptoms.

there are findings on examination

a definitive diagnosis of a disability should be rendered by the examiner.
Example: Examiner diagnoses “left knee patellofemoral syndrome” and examination shows limited range of motion with pain.
Important: The following are not sufficient for rating purposes

  • non-committal diagnoses, such as

  • rule-out, or

  • differential, and

  • assigning symptoms as a diagnosis, such as

  • pain

  • tenderness, or

weakness.

a disability exists but a definite name cannot be given

the examiner should describe the disability and indicate that it is of unknown etiology.
Example: “Respiratory insufficiency of unknown etiology.”

the examiner states further studies, evaluations, or laboratory tests are needed

the additional studies, evaluations, or testing must be performed before the diagnosis on examination can be considered final.

a previously established diagnosis is changed by the examiner

the examiner must state whether the current diagnosis represents

  • a new disability, or

a progression of the former disability.




Reference: For more information on handling examinations insufficient for rating purposes, see M21-1, Part III, Subpart iv, 3.D.3.




m. Questions About Competency and/or Validity of Examinations

Ensure that you consider concerns raised by the claimant or his recognized representative about a completed examination or opinion. Communications raising concerns may take the form of (but are not necessarily limited to):
complaints about the examiner

requests for information about the examiner’s qualifications

assertions that records or other relevant information or evidence was not considered, or

requests for another examination or opinion.


The mere fact that such a communication is received does not mean that the examination is insufficient or in need of clarification or that there is a further duty to assist to obtain records or another examination. However consideration must be given to whether one or more of those remedies is appropriate.
The table below provides guidance on interpreting communications from claimants or representative raising concerns about examinations and what action to take as applicable.




If the substance of the communication is ...

Then ...

that the examiner was not qualified to perform the examination or issue the opinion.

review M21-1, Part III, Subpart iv, 3.D.2.b and additional blocks in this topic on qualifications for specific types of examinations, and

consider the guidance on competency of medical evidence in M21-1, Part III, subpart iv, 5.2.


When that review leads to a conclusion that the examiner did not have the appropriate qualifications, or otherwise that the conclusions of the examination or opinion were not competent, another examination is required.
However where an examiner is basically competent, matters like specialty, Board certification, experience and other related considerations will merely be considerations in determining probative value of the examination or opinion.
Note: tThere is a presumption that a selected medical examiner is competent.

that the examination was not sufficient or requires clarification.

Rreview M21-1, Part III, Subpart iv, 3.D.3 and 4 and take any action required by those topics.

that additional material evidence must be obtained to substantiate the claim

Rreview M21-1, Part I, 3.C on the duty to assist.





Note: VA’s compensation and pension claim adjudication system does not have a procedure for completion of interrogatories by VA personnel. Interrogatories are written questions that, in some court proceedings, must be answered under oath. If the claimant or representative submits a communication characterized as interrogatories

do not

complete and return the document, and

do not refer it to the examiner, but

do

look at the substance of the communication as indicated above in this block, and

determine if it is raising questions about examiner competency, adequacy of the examination or satisfaction of the duty to assist.
References: For more information on


  • a claimant’s request for information, or complaints, about a VA examination or opinion, see Nohr v. McDonald, 27 Vet.App. 124 (2014), and

challenging the expertise of a VA examiner, see Bastien v. Shinseki, 599 F.3d 1301,1307.(Fed.Cir.2010).



n. Handling Unusual Cases

If necessary, the VSCM or PMCM should discuss unusual cases with health care officials to ensure proper understanding of the issue or issues at hand.



o. Accepting a Fee-Based Examiner’s Report

There is no prohibition against acceptance of a VA examination for rating purposes from a fee-based medical examiner who has previously submitted a statement on the claimant’s behalf.




p. Examiner Statements that an Opinion Would be Speculative

Pay careful attention to any conclusion by the examiner that an opinion could not be provided without resorting to mere speculation (or any similar language to that effect).
Per Jones (Michael H.) v. Shinseki, 23 Vet.App. 382 (2010), VA may only accept a medical examiner’s conclusion that an opinion would be speculative if
the examiner has explained the basis for such an opinion, identifying what facts cannot be determined, or

the basis for the opinion is otherwise apparent in VA’s review of the evidence.


If an examiner’s conclusion is not adequately justified, the report may be insufficient for rating purposes. Seek clarification of the conclusion.
Note: If the examiner specifically states that a medical opinion cannot be provided unless specific evidence is made available, VA’s duty to assist requires that VA determine whether that evidence may be reasonably obtained. If so, VA is to make efforts to obtain it and then seek an additional medical opinion which considers the relevant information.
Reference: For more information on speculative opinions, see Daves v. Nicholson, 21 Vet. App. 46 (2007).



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