Courtney Ross: Good afternoon and welcome to CCK Live with Chisholm
Chisholm & Kilpatrick. I'm Courtney Ross and joining me today is Brandon Paiva
and Kaitlyn Degnan. And today, we are going to be talking about mental health C&P exams.
So, let's jump right in with what is a C&P exam? So, Kaitlyn, I'm going to turn to you first if you
can give us a little bit more context to what a C&P exam actually is and how VA uses them.
Kaitlyn Degnan: So, a C&P exam or a compensation and pension exam, are medical exams that are
ordered by VA to evaluate the conditions that a veteran is claiming for disability compensation.
These are meant to assess either the etiology and severity of a veteran's conditions and are part
of VA's duty to assist veterans and obtaining evidence to support a disability claim. And
it's important to know what's being evaluated at your C&P exam. Whether it be the examiner is
attempting to determine the etiology or the cause of a condition to establish service connection,
or if the examiner is looking at the severity to help determine your rating.
Sometimes the examiner could be looking at both.
These are conducted by VA-contracted third-party medical professionals, and they are a
very important part of the disability claims process because VA will frequently give
more weight to the findings of the C&P examiner than they might to your actual treating doctor.
Courtney: Yeah, and that last point is really important,
VA definitely puts a lot of weight on these exams which is why, you know,
we thought this video is important and this information is a good resource to have.
So, if a veteran file a claim for service connection for a psychiatric condition or
a claim for an increased rating for a psychiatric condition that they might
already be service-connected for, VA is likely to order a C&P examination to evaluate that
mental health condition. And, you know, the information that's included in the exam might
vary depending on if it's a service connection or an increased rating claim.
So, Brandon, I'm going to turn to you, if you can take us through,
you know, what an evaluation of a mental health condition might look like in one of
these exams and the types of information that might be recorded by the examiner.
Brandon Paiva: Sure thing! So, generally speaking, VA uses criteria from the diagnostic
and statistical manual of mental disorders —the 5th edition, I believe we're on now,
otherwise known as DSM-5 — and it uses it in order to evaluate whether there is a valid diagnosis
of a mental health condition during that compensation and pension exam.
Common conditions include anxiety disorders
like panic disorder; trauma and stress-related disorders like post-traumatic stress disorder;
psychotic disorders like schizophrenia; cognitive disorders; eating disorders
like anorexia and bulimia; mood disorders, something like major depressive disorder;
and even residual effects of traumatic brain injuries or residual effects of a TBI.
Before the exam, the examiner should review the veteran's entire claims file and look
for any evidence that may be related to the veteran's claimed condition. So,
at least the examiner is going in with a well-informed, sort of, background and kind
of know what they're going to be evaluating before the veteran actually enters the examination room.
The medical examiner will typically ask the veteran questions about how their condition
affects them on a daily basis. Most of these questions will vary based on your claim:
whether you're filing a claim for a psychiatric condition or mental health condition,
you know, whether you're filing for service connection,
or whether you're at the C&P exam to try to get an increased rating.
They may also complete a disability benefits questionnaire, which you may also know as a DBQ.
Essentially, the DBQ uses check boxes and standardized language to evaluate
the veteran's disability quickly and correctly. Specifically, healthcare providers will check a
box, so to speak, next to a description that most accurately depicts the veteran's disability that's
in question. The DBQ also addresses the veteran's level of social and occupational impairment, which
sometimes could help with the claim for Total Disability based on Individual Unemployability,
or TDIU. For example, the level of impairment due to depression ranges from no diagnosis
to total occupational and social impairment, with various levels in between the two.
Assuming a veteran meets all the criteria from the DSM-5 necessary for a diagnosis of their
specific condition, the symptoms section of the DBQ will then help determine the
appropriate disability rating. So basically, based on the severity of your condition
will directly correlate to the amount of compensation or the amount of disability,
as far as the percentage rating, that VA is going to give you for that condition.
It's important to veterans, what's really important is that the veterans that
attend the compensation and pension examinations are always honest and upfront with the C&P
examiner about their symptoms and about the way that their condition impacts their life.
We know that oftentimes our clients, or maybe other veterans going to C&P exams for
mental health conditions, and sometimes they may try to, you know, put on a front where
they believe like they're handling their conditions a lot better than they may be.
So, really making sure that you're being honest and reporting what your daily stressors are like,
or kind of what it's like to live a day in your shoes, dealing with these mental and
psychiatric conditions, is really going to help give insight and at the end of the day,
it's really only going to help the examiner give the VA a more accurate description in a more
accurate depiction of your disability and sort of the impairments that come with that disability.
Courtney: Thanks, Brandon. I think you highlight an important point that
kind of echoes what something Kaitlyn said in the beginning again is that,
you know, VA relies significantly on these examinations in the mental health context when
they're even assigning an increased rating or service connection has been granted and so
they're assigning, you know, the initial rating — they're really going to rely on this mental health
C&P examination that's been completed to look at the symptoms that the examiner has documented or,
you know, the boxes that they've checked off in the DBQ that you've referenced if there is
one. And so, the information that's recorded in these examinations is really important.
So, you know, I want to quickly touch on how VA actually rates the mental health
conditions because a lot of the language in the criteria that VA uses actually correlates almost
directly to the language that's included in the DBQ for the examiners to check off,
you know, the appropriate box. So, after an exam is complete, like I said, if VA grants
service connection, they'll be assigning a rating for the mental health condition. Or if they're
granting an increased rating they'll obviously be assigning an increased rating for that condition.
So, VA rates all mental health conditions, aside from eating disorders, using the same diagnostic
criteria. Specifically, they rate them under 38 CFR 4.130. And there are different diagnostic
codes within that regulation that will be assigned depending on the diagnosis of the mental health
condition. But the criteria that VA uses is the same regardless of the actual diagnosis.
And so, ratings for mental health conditions, again, to echo what Brandon said,
vary depending on severity. A condition can be rated in 0%, 10%, 30%, 50%, 70%,
or 100%. And the rating that gets assigned is based on what the evidence speaks to as far
as the level of social and occupational impairment.
And within the criteria for each of those ratings — so, 0, 10, 30, 50, 70, a 100 — it lists a number
of symptoms that might demonstrate the appropriate level of social and occupational impairment for
that specific rating. You know, it's really about the frequency, duration, and the severity
of the symptoms listed in the criteria. And it's important to know that if you're reviewing it,
it's not an exhaustive list, and you don't have to check off that you have every symptom listed
in the 70% criteria to be able to establish that you're entitled to the 70%. Again,
it's about showing that the frequency, duration, and severity of the symptoms you do have equate to
the level of social and occupational impairment that VA's looking at for that specific rating.
We have in-depth CCK videos on mental health ratings on our YouTube channel. So,
if you are looking for more specific information on how VA rates mental health conditions or what
kind of evidence you might be able to submit to establish what rating you're entitled to,
please do check out those videos on YouTube. They go into a lot more detail
and hopefully will be a good resource for you.
So, Kaitlyn, I'm going to turn back to you. I hinted at this a little bit, but can you
talk about if veterans need to meet all of the criteria in the obvious mental health rating
criteria that they've set out and maybe provide an example to give a little bit
more context as to what we mean when we say they shouldn't have to.
Kaitlyn: So, no, veterans don't need to show every single symptom in the rating criteria to receive a
particular disability evaluation. Since mental health conditions can manifest differently in
each individual, these rating criteria allow for some flexibility. And symptoms that are
listed at each level of the rating formula are just examples meant to demonstrate the kinds of
symptoms that result in the level of impairment required by each of those various ratings.
So, for example, a veteran might have an anxiety condition and he or she might get so anxious
that they pick at their skin, causing physical harm to themselves. Now, that's not explicitly
listed anywhere in the rating criteria. However, that symptom is similar to an obsessive ritual
that interferes with routine functioning, and that's a symptom that we know can warrant a 70%
disability rating. So, even though that veteran's symptoms don't exactly ascribe to what's in the
rating criteria, that symptom can still be used to demonstrate entitlement to a higher rating.
Courtney: Thank you. I think that example is helpful to give a little bit more context
to what we mean when you're looking at evidence you might have of your own symptoms as a veteran
and then comparing it to what VA lists in the criteria itself in the regulation.
So, Brandon, I'm going to turn back to you. You know, I mentioned that VA rates all mental health
conditions under the same criteria. What happens if a veteran has multiple mental health conditions
that they believe are due to service or VA has already conceded is due to service, so let's say
PTSD and depression. Does VA provide two separate ratings for both depression and PTSD?
Brandon: So, that's a really good question. So, we're going to really touch on, you know,
veterans who have both of those conditions. So, essentially, the short answer to your question is
no, you're not going to get separate ratings for those conditions. And we'll sort of provide some
similar detail in just a few minutes as to kind of what that means, and kind of how VA accurately
rates a veteran, even though that he or she may suffer from multiple psychiatric conditions.
So, psychiatric disorders as you had stated, Courtney, can sometimes be difficult to tell
apart or separate, as many disorders oftentimes have overlapping symptoms. And very similarly,
you know, mental health conditions are oftentimes connected to one another.
For example, it's really common for veterans to develop depression or anxiety
as secondary or as a result of their PTSD. So, they can have PTSD and also be diagnosed
with major depression or anxiety. However, VA, like I had stated, doesn't rate each condition
separately under its general rating formula. Instead, veterans with multiple mental health
conditions will likely be assigned one combined rating, and oftentimes VA will only assign
one rating for that mental health condition, for that psychiatric condition.
VA exams will typically address this. Usually, the DBQ form will ask if a veteran has multiple
psychiatric conditions and, sort of, ask the examiner to maybe separate some of
those symptoms there. But veterans can only be rated for a symptoms functional limitation
once and this is very generally called pyramiding which we'll get into in a little bit.
So, just to kind of provide a little more context and another example that might make
it a little bit more digestible, veterans who suffer from PTSD might also have a diagnosis
of major depressive disorder. If VA has conceded that both of those conditions
are attributed to the veteran's service, the veteran isn't going to receive a 50%
rating for PTSD and then a separate 30% rating for their major depressive disorder. Rather,
the veteran may receive a combined 70% rating under the diagnostic code for one condition.
Essentially, to have the same symptom be considered under more than one diagnostic
code is called pyramiding, which VA regulations strictly prohibit us from doing. We have a number
of blog posts and some other information on our CCK website if you're interested in learning about
pyramiding as well. But essentially, you can't have the same symptom, like I had said, rated for
two separate conditions. Essentially, they have to kind of be accredited to one. Like I have used the
example with veterans who oftentimes have comorbid psychic conditions, more often than not, they'll
kind of rate you under one condition and give you one assigned rating based on those symptoms.
Courtney: Thank you, Brandon. I think that example helps to kind of demonstrate exactly what
was meant by pyramiding as well. And as Brandon said, we do have a video
specifically on pyramiding on our YouTube channel, so you should also,
if you're looking for more information on that, feel free to check that out.
So, I want to wrap up with just getting your thoughts on
some general tips that are helpful for veterans to keep in mind if
a VA examination or seeing if a VA exam for their mental health condition has been ordered.
I'll start with one that I think is probably one of the most important
and critical pieces of advice I think we can give, and that is to attend your examination. If
VA schedules you for one, make sure that you can attend. If for any reason that you can't attend,
you should make sure that you're reaching out to VA to get it rescheduled. If you failed to
attend an examination that's been scheduled and you're unable to provide good cause as to
why you were unable to attend it, VA is likely going to just issue a denial of
the claim or appeal that you have pending without considering any further evidence.
So, it's critical that you attend your exam or make sure that you coordinate with VA getting it
rescheduled so that you don't end up with a denial in your hands and a missed exam.
Kaitlyn, do you have any additional tips that you think would be helpful to share?
Kaitlyn: Yep. So, I think Brandon touched on this earlier, but it's so important to
be honest with your examiner. That means don't underreport your symptoms, right? Don't, you know,
pretend like you have a handle on things when you're really experiencing more serious symptoms.
But that also means don't over-report your symptoms, right? That can affect
your credibility to the examiner which can cause more problems later on down the line. It's really
important to explain to the examiner what are you experiencing on a day-to-day basis, how does
your condition affect your ability to function at work, function at home, function with your family,
all aspects of your life. All of that is such important information to give to the examiner.
Courtney: I think that's a really good one. And again, I think it's so critical,
you've kind of heard that theme throughout the video here today.
Brandon, what about you. Any additional thoughts or tips that you
think would be helpful for viewers to know?
Brandon: Yes, most veterans, you know, maybe our clients or other veterans sort of going
through the appellate system with VA. One thing I'd probably say is, be aware that you can bring
somebody with you to the exam if you feel as though they can offer additional information or
if you're not comfortable going to the examination alone. Oftentimes veterans
don't know that they can bring their spouse, you know, their caretaker, or whoever with
them to the examination if they're uncomfortable with sort of attending the examination alone.
One thing that we see as sort of a benefit to bringing somebody with you, now, we don't
want you to take this the wrong way, we're not saying, you know, invite the whole household,
but you know, maybe one individual will be allowed in the examination room with you. So,
kind of using the example of a spouse, if kind of like what Kaitlyn had said, if you feel like you
have a tendency to underreport your symptoms. Or if you feel like you have a stronghold on things,
but your spouse believes that no, you do not or that, you know your spouse kind of notices other
symptoms, maybe other rituals that you know, maybe you're not aware that you kind of do,
they can speak to those sort of symptoms and those sort of rituals or anything like that,
on your behalf as well. So, that usually helps with individuals who tend to underreport things.
So, don't be afraid to bring, you know, maybe another spouse or a close family member or
somebody who has a very close relationship with you and maybe somebody who can attest
to the symptoms that you are experiencing as well. Again, we're not saying bring, you know,
your entire household with you, but maybe one other individual that you feel like would be
able to help you throughout this process is perfectly able to attend the examination with you.
Courtney: Yeah, that's another really great point. One other thing, I think it's important to keep
in mind and it's you know along the lines of what we've been saying is, keep in mind that
examiners are also observing you from the time that you walk in the door. And I don't just mean
in the door with the exam room. If you're waiting in the waiting room to be called in,
any of your behaviors that might be observed by the examiner while you're waiting,
are fair game for them to include an examination. So, this means that the moment you walk into that
waiting room, examiners might be observing your interactions with other patients
or the staff while you wait. And so, that's just something to be mindful that it's not,
it may not just be limited to the time period that you are in the actual examination room.
So, with that, I'll just throw it out if anyone has any last tips that
they want to share with everyone before we wrap up today's video?
Kaitlyn: So, I think one other important thing to remember that I don't know if
we've touched on—veterans do have the right to challenge an unfavorable examination. So,
after you go for this C&P examination, you can ask VA for a copy of it. You can look at it,
and if you think the examiner got something wrong or maybe misconstrued something that you said,
you can tell VA that, you can challenge that and then even further down the line, you know,
if you do, unfortunately, receive a denial and it does have to be appealed, you know, looking at
the examination and any deficiencies that might be there is one way that you can challenge that. So,
you're not stuck with whatever the examiner says. You do have the ability to rebut it.
Courtney: Yeah, an excellent point. And, you know,
if you are interested, we have a lot of videos on C&P examinations, generally,
and some that are similar to this one where it's focused on a specific type of condition, where we
talk a lot in a lot more detail about challenging examinations and maybe ways to go about doing so.
So, I would encourage all of you to check out our videos on our YouTube channel,
and thank you all for joining us today. And thank you, Kaitlyn and Brandon.
[END]