Compensation and Pension (C&P) Exams for PTSD
VA Disability Compensation for Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a psychiatric condition commonly experienced by veterans as a result of their military service. Nonetheless, veterans must show a link between their PTSD and military service in order to receive disability compensation. To establish service connection, the following elements must be present: (1) a current diagnosis of PTSD; (2) an in-service stressor; and (3) a medical nexus between your PTSD and in-service stressor. When it comes to a medical nexus opinion, VA will likely order a Compensation and Pension examination (C&P exam) in order to have a doctor opine on whether your PTSD is related to your service.
Compensation and Pension Examinations
C&P exams are medical exams ordered by the Department of Veterans Affairs to evaluate the conditions that a veteran is claiming for disability compensation. These exams are meant to assess the etiology and/or severity of a veteran’s condition and are part of VA’s duty to assist veterans in obtaining evidence to support their disability claims. Either a VA medical professional or a third-party medical professional contracted by VA will conduct the exam. Before a C&P exam for PTSD, the examiner will review the veteran’s entire claims file and look for any evidence that may be related to the condition.
Generally speaking, VA will not schedule a C&P exam for PTSD until there is some indication of two or three of the criteria for service connection. For example, there should be at least some indication that there was an event or an injury in service and some medical evidence suggesting a possible diagnosis. The purpose of a C&P exam is typically to establish that final, missing element of service connection: the medical nexus.
Importantly, a C&P exam for PTSD is not used for treating purposes and sometimes the examiners will even specify that. Namely, the examiner may state, “I am here to assess your condition only, I am not here to provide treatment.” Basically, this means that the veteran’s interactions with the examiner are likely limited to these circumstances. The veteran will not be returning for therapy or treatment and the examiner is not going to prescribe any medication or suggest therapeutic interventions. Again, the purpose of a C&P exam for PTSD is to determine whether service connection or a higher disability rating is warranted.
Who Conducts C&P Exams for PTSD?
Generally speaking, VA-approved psychologists, psychiatrists, or other mental health professionals are going to conduct the C&P exam for PTSD. The examiner could be employed by VA directly or as an independent contracter. Regardless, the examiner is supposed to have access to and review the veteran’s full claims file prior to the examination. They have access to any medical records, lay statements, and treatment notes that may be relevant to the veteran’s claim. If you attend a C&P exam for PTSD and the examiner does not check off that they have reviewed your entire claims file, you could later use that piece of information to challenge the results of the exam (if unfavorable).
What to Expect Before the PTSD C&P Exam
In some cases, veterans are given the PTSD Checklist for DSM-5 (PCL-5) to complete while sitting in the waiting room before their appointments. This is meant to be an initial assessment of both the presence and severity of the veteran’s PTSD symptoms. It is a short 20-question checklist where veterans are asked to go through and respond to specific things that they are experiencing over a certain period of time. Then, the examiner will use this to gauge the veteran’s initial symptoms reported prior to the exam.
How Does VA Evaluate PTSD During the C&P Exam?
During a C&P exam for PTSD, the medical examiner will likely complete a Disability Benefits Questionnaire (DBQ). A DBQ uses check boxes and standardized language so that the disability evaluation can be made quickly and correctly. Specifically, healthcare providers will “check a box” next to a description that most accurately depicts the disability in question – in this case, PTSD. However, it is important to note that a DBQ will not be used if the veteran is undergoing an initial exam for PTSD.
The DBQ for PTSD will go through all of the aspects that are required in the DSM to determine whether the veteran meets criteria. Importantly, the form is not something that the veteran can fill out and submit on their own. Rather, it must be completed by a medical professional.
Diagnosing PTSD During a C&P Exam
VA uses criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) to evaluate whether there is a valid diagnosis of PTSD. This diagnostic criteria section of the DBQ is broken down into six categories (Criteria A-F). The subsequent section lists additional symptoms related to PTSD. Assuming a veteran meets all of the criteria from the DSM-V necessary for a PTSD diagnosis, the symptoms section of the DBQ will then help determine an appropriate disability evaluation.
Another important section of the DBQ addresses the veteran’s level of occupational and social impairment. Here, the level of impairment due to PTSD ranges from no diagnosis to total occupational and social impairment, with various levels in between. Veterans should be honest and forthcoming about how their PTSD affects their everyday life. Doing so will further help the examiner see the full extent of the condition.
The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) may also be administered during the C&P exam. It is usually provided in a structured 30-minute interview during which the examiner asks questions that are intended to gauge what the veteran’s PTSD symptoms are, the duration and onset of those symptoms, how they affect the veteran in terms of occupational and social impairment (e.g., work, family, relationships, etc.).
If the veteran’s case for PTSD was certified to the Board prior to August 4, 2014, then the veteran may use their Global Assessment of Functioning (GAF) scores as evidence. VA previously used GAF scores to evaluate the severity of PTSD before switching to the DSM-5. GAF scores are no longer used as they were found to be less reliable in determining the severity of symptomology.
What if the C&P Examiner Finds You Have a Mental Health Condition Other Than PTSD?
If the examiner happens to diagnose the veteran with a mental health condition that is not PTSD, but is related to their service, service connection can still be awarded. When adjudicating the claim, VA is supposed to take any mental health diagnosis that is linked to service and grant service connection regardless of what the veteran filed the claim for.
How VA Assigns Disability Ratings Following C&P Exams for PTSD
After the C&P exam is complete, VA adjudicators will review it along with all of the other evidence in the veteran’s claims file. Specifically, VA rates PTSD under 38 CFR § 4.130, Diagnostic Code 9411, and assigns a disability rating ranging from 0 to 100 percent. The rating assigned is based on the level of social and occupational impairment, and the frequency, duration, and severity of symptoms. However, there are many times in which veterans believe their PTSD warrants a higher disability rating than the one assigned by VA. In this case, veterans have the right to appeal for a higher rating. When a veteran files for an increased rating for their PTSD, VA will likely send them to another C&P exam that will focus mainly on the severity of the condition.
It is important to note that the symptoms listed in the PTSD rating criteria are not an exhaustive list. This means that veterans are not required to have every single symptom listed to meet the criteria for that rating percentage. VA should assign the higher disability rating even if only some of the criteria are met.
Common Reasons for Unfavorable PTSD C&P Exam Results
One of the most common mistakes seen in C&P exams for PTSD involves VA misapplying the law. Specifically, VA may require a direct causal relationship or direct medical evidence of continuous symptomology over the years instead of applying the “at least as likely as not” (i.e., 50-50 chance) standard. Another common issue is the suggestion on the part of the VA examiner that the veteran is malingering, meaning that they are exaggerating some of their symptoms or over-reporting certain aspects. Fortunately, there are several ways to combat unfavorable C&P exam results.
What to Do If You Disagree with Your PTSD C&P Exam Results
If you disagree with your PTSD C&P exam results, you may submit private treatment notes and medical records to provide more favorable evidence. Such medical records should also be given consideration during the adjudication process. Veterans are entitled to go to outside doctors and obtain opinions to be weighed against VA examinations. Therefore, if you have additional evidence in support of your PTSD claim, it may be beneficial to submit it to VA following your C&P exam. Veterans are able to challenge their C&P exam for PTSD.
Importantly, VA cannot just blankly accept the VA examination as being more probative than the private medical opinion. Instead, it comes down to not only what the opinion contains in terms of positive or negative results, but also the evidence that the examiners considered in rendering their opinions. Each examiner must provide a detailed explanation for their conclusions. If the VA examiner only checks a few boxes and does not provide an explanation, the exam is not adequate for rating purposes. Likewise, VA must provide adequate rationale for deciding one of these medical opinions has more probative value. If VA does not do so, the veteran can rebut VA’s determinations.
Tips for Attending C&P Exams for PTSD
First and foremost, veterans must attend the C&P exam for PTSD. Failure to do so without providing good cause can result in VA denying your claim without looking into further evidence. However, once you are at the C&P exam, there are several steps you can take to ensure VA is addressing your concerns fairly and appropriately. First, you should always be as honest as possible. Do not under- or over-report your symptomology. Instead, make sure to carefully explain to VA what you are experiencing on a daily basis and how it affects your functioning. Second, 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 do not feel comfortable attending alone. Finally, remember that VA examiners are likely to observe you from the very beginning. This means that from the moment you walk into the waiting room, examiners may observe your interactions with other patients and the staff.
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