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September 15, 2010

C&P Examinations, VHA Handbook 1601E.01, February 2010

Filed under: Uncategorized — Tags: , — veteranclaims @ 5:42 pm

At a minimum, the examination report
must contain
:
(1) A statement of the issues cited from the examination request.
(2) A statement by the examiner that the C-File was or was not reviewed.
(3) A statement of the chief complaint(s).
(4) A history of the present illness including a chronological description of the development of the presenting condition from the date of discharge or the last examination.
(5) An up-to-date brief psychiatric and psychosocial history for all mental health
examinations.
(6) Pertinent military, occupational, medical, family and social history.
(7) Pertinent subjective complaints.
(8) A complete description of objective findings stated in concrete terms.
(9) A diagnosis of all described conditions, including an A 5-axis diagnosis utilizing the most recent Diagnostic and Statistical Manual (DSM) for all mental health examinations. NOTE: To be complete, mental health diagnoses should be “multi-axial.” The first axis is the “usual” diagnosis like Post-Traumatic Stress Disorder, major depression, or schizophrenia. The second
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October 13, 2009
VHA HANDBOOK 1601E.01
5
action indicates any associated personality disorders. The third axis indicates any associated general medical conditions. The fourth axis indicates the level of stress. The fifth axis indicates current functioning.
(10) Answers to any questions specifically requested in the examination request.
(11) Opinions specifically requested in the examination request, including specific evidence reviewed and considered in formulating the opinion, a thorough rationale for the opinion rendered, and expressed using legally-recognized phrases.
(12) A diagnosis or notation that a chronic disease or disability was ruled out for each
disability, complaint or symptom listed on the examination request.
(13) The clinic findings required by the rating schedule for the evaluation of the specific disability being claimed.
NOTE: Disability examination worksheets contain specific instructions of elements that must be addressed during the examination. Disability examination worksheets are available at:
http://vbaw.vba.va.gov/b1/21/rating/rat00.htm.
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T-1
Department of Veterans Affairs
VHA HANDBOOK 1601E.01
Veterans Health Administration
Transmittal Sheet
Washington, DC 20420
October 13, 2009
COMPENSATION AND PENSION (C&P) EXAMINATIONS
1. REASON FOR ISSUE. This Veterans Health Administration (VHA) Handbook reduces the
average processing time of Compensation and Pension (C&P) examinations from 35 days to
30 days.
2. SUMMARY OF MAJOR CHANGES. This revision to VHA Handbook 1601E.01 reduces
the average processing days from 35 days to 30 days.
3. RELATED ISSUES. VHA Directive 1600 (to be published).
4. RESPONSIBLE OFFICE. The Chief Business Office (16) is responsible for the contents of
this VHA Handbook. Questions may be addressed to Chief Business Office at (202) 461-1589.
5. RESCISSIONS. VHA Handbook 1601E.01, dated April 3, 2006, is rescinded.
6. RECERTIFICATION. This VHA Handbook is scheduled to be recertified on or before the
last working day of October 2014.
Gerald M. Cross, MD, FAAFP
Acting Under Secretary for Health

DISTRIBUTION: E-mailed to the VHA Publication Distribution List 10/14/09
Corrected Copy
2/25/2010
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October 13, 2009
VHA HANDBOOK 1601E.01
1
CONTENTS
COMPENSATION AND PENSION (C&P) EXAMINATIONS
PARAGRAPH
PAGE
1. Purpose ………………………………………………………………………………………………………………….. 1
2. Background ……………………………………………………………………………………………………………. 1
3. Authority ……………………………………………………………………………………………………………….. 1
4. Scope …………………………………………………………………………………………………………………….. 1
5. Responsibility of the Facility Director ………………………………………………………………………. 1
6. C&P Examinations Request ……………………………………………………………………………………… 2
7. Timeliness Requirements …………………………………………………………………………………………. 3
8. Examination Reports ……………………………………………………………………………………………….. 4
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October 13, 2009
VHA HANDBOOK 1601E.01
1
COMPENSATION AND PENSION (C&P) EXAMINATIONS
1. PURPOSE
This Veterans Health Administration (VHA) Handbook establishes procedures for
administering the Compensation and Pension (C&P) Examination Program.
2. BACKGROUND
Veterans may submit claims to the Veterans Benefits Administration (VBA) for service-
connected compensation or non-service connected pension benefits. If necessary to adjudicate a disability claim, or if the Veteran does not provide sufficient documentation to establish a claim for disability compensation, a medical examination may be provided. Generally, these examinations are provided by a Department of Veterans Affairs (VA) health care facility.
However, in some circumstances, reports submitted by a private physician may be accepted. In some instances, examinations by non-VA providers may be authorized at VA expense.
3. AUTHORITY
The authority is found in Title 38, Code of Federal Regulations (CFR), Sections 3.326 and
CFR § 3.159 .
4. SCOPE
When a disability compensation or pension examination is requested for rating purposes, the examination is provided in accordance with 38 CFR § 3.326. An examination will be provided in accordance with 38 CFR §3.159 whenever a C&P examination is requested for either of the following purposes:
a. For determining the current disability, whether a current diagnosed disability is related to an event, injury, or disease in military service; or
b. For providing other medical evidence necessary to a VA decision concerning entitlement
to disability compensation.

5. RESPONSIBILITY OF THE FACILITY DIRECTOR
The facility Director is responsible for ensuring processes are in place that provide for the processing of examinations requested in connection with the adjudication of claims for VA disability compensation or pension benefits as quickly as possible.
a. C&P examinations are a high-priority workload and are to be processed within the
guidelines as stated in this Handbook and the C&P Procedure Guide found at:
http://vaww1.va.gov/CBO/policy/policyguides/index.asp?mode=contents&id=V . NOTE: This
Web site is for internal VHA use only.
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VHA HANDBOOK 1601E.01
October 13, 2009
2
b. Under Title 38 United States Code (U.S.C.) Section 5103A, VHA may provide an
examination or a medical opinion as part of the C&P claims process.
(1) VHA must provide an examination, when necessary, under the duty to assist provisions of
38 U.S.C. Section 5103A and 38 CFR Section 3.159 equally to incarcerated Veterans as to
non-incarcerated Veterans.
(2) In claims for disability compensation, examinations under 38 CFR Section 3.159 are
performed to provide sufficient competent medical evidence to decide a claim; e.g., to determine the current disability or to determine whether a current diagnosed disability is related to an event, injury, or disease incurred while in military service.
c. Examinations under 38 CFR Section 3.326 are performed to assist in the establishment of disability ratings in conjunction with benefits claims.
NOTE: A comprehensive general medical and psychiatric examination usually provides both
the diagnosis and symptomatology sufficient to identify a condition and determines the extent to which a Veteran is disabled.
6. C&P EXAMINATIONS REQUEST
a. Examinations may be requested for:
(1) Veterans.
(2) Pensioners and Veterans of certain nations allied with the United States in World War I and World War II, upon authorization from accredited officials of the respective governments.
NOTE: Allied beneficiaries are managed manually outside of the Automated Medical
Information Exchange/Compensation and Pension Record Interchange (AMIE/CAPRI) software
within the Veterans Information Systems and Technology Architecture (VistA) software.
Veterans who are employees of VA have their examinations performed at an alternate VA
location from the location of their employment. For more information on allied beneficiaries, see the Non-Veteran Beneficiaries Procedure Guide at:
http://vaww1.va.gov/CBO/policy/policyguides/index.asp?mode=contents&id=IV , which is for
internal VA use only.
(3) Non-Veteran claimants and Veterans’ beneficiaries in determinations of benefits claims.
b. Electronic C&P Examination Requests. Regional offices (ROs) must request any
examinations, including requests for observation and examination (O&E), using the
AMIE/CAPRI C&P examination request option that electronically transmits the request to the VA health care facility of jurisdiction. NOTE: Examination requests must specify the types of examinations needed and any special reports or studies required. Requests made by the Tiger Team that are initiated by the Cleveland RO are expediently managed manually.
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VHA HANDBOOK 1601E.01
3
c. Making Determinations Concerning Examination Requests
(1) The VA health care facility that receives the examination request determines as soon as possible after the receipt of the request, who, in accordance with the VBA guidance, may perform an examination and where and how to conduct the examination.
(2) The VA health care facility may refer special cases to another VA health care facility or authorized fee-basis provider, Sharing Agreement, or contractual facility that is staffed and equipped to perform the required examination. NOTE: For more information on timeliness, see C&P Procedure Guide found at:
http://vaww1.va.gov/CBO/policy/policyguides/index.asp?mode=contents&id=V . NOTE: This
is an internal Web site and is not available to the public.
d. Requesting Specialist Examinations
(1) The RO may specifically request specialist examinations on the AMIE/CAPRI C&P
examination requests.
(2) The physician, or for a mental examination physician or doctoral level psychologist,
examiner has the authority and responsibility to request a specialist examination in individual
cases when deemed necessary. NOTE: Approval of the request, by the Associate Chief of Staff for Ambulatory Care or the Clinical Director, or designee, may be required.
7. TIMELINESS REQUIREMENTS
a. Timeliness for Completion of Examinations and Required Tests
(1) VHA has a time standard of 30 calendar days on average, after receipt of the examination request, to complete the examinations and required tests.
(2) The 30 calendar day standard is measured from the day the properly-completed request
for examination(s) is received by VHA through the day when all the components, including
laboratory and ancillary test results, are released or returned to VBA. NOTE: For more
information on managing C&P examination reports, see the C&P Procedure Guide found at:
http://vaww1.va.gov/CBO/policy/policyguides/index.asp?mode=contents&id=V . NOTE: This is
an internal Web site and is not available to the public.
b. Timeliness for Fee-Basis Examinations. The appropriate program office responsible for
the day-to-day oversight of the C&P programs must ensure a follow-up system is required for the examinations that are authorized to fee physicians to ensure that they are completed within the established time and that the payments for services are made promptly.
c. Timeliness for Availability of Examination Reports. The appropriate program office
responsible for the day-to-day oversight of the C&P program is responsible for:
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VHA HANDBOOK 1601E.01
October 13, 2009
4
(1) The documentation of examination reports and results of tests must be completed and
available within 2 calendar days of the completion of the examination or tests.
(2) The completed examinations must be returned to the requesting RO within 3 calendar
days of completion of the examination or tests.
NOTE: For more information on timeliness requirements, see the C&P Procedure Guide found
at: http://vaww1.va.gov/CBO/policy/policyguides/index.asp?mode=contents&id=V . NOTE:
This is an internal Web site and is not available to the public.
8. EXAMINATION REPORTS
a. C&P Examination Forms. C&P examinations are to be conducted in accordance with the
format on the AMIE/CAPRI C&P examination worksheets and the Physician’s Guide for
Disability Evaluation Examinations and other applicable VBA and VHA guidelines. NOTE:
C&P examination worksheets, Physician’s Guide for Disability Evaluation Examinations and
other references are available at http://vaww4.va.gov/cpep/cguide/main/toc.htm.
b. Form for Reporting Examination Results Unless the requesting agency provides
specific forms, examinations are reported electronically through AMIE/CAPRI or VistA
packages that support AMIE/CAPRI (e.g., QUASAR).
c. Information Required for Examination Reports. At a minimum, the examination report
must contain
:
(1) A statement of the issues cited from the examination request.
(2) A statement by the examiner that the C-File was or was not reviewed.
(3) A statement of the chief complaint(s).
(4) A history of the present illness including a chronological description of the development of the presenting condition from the date of discharge or the last examination.
(5) An up-to-date brief psychiatric and psychosocial history for all mental health
examinations.
(6) Pertinent military, occupational, medical, family and social history.
(7) Pertinent subjective complaints.
(8) A complete description of objective findings stated in concrete terms.
(9) A diagnosis of all described conditions, including an A 5-axis diagnosis utilizing the most recent Diagnostic and Statistical Manual (DSM) for all mental health examinations. NOTE: To be complete, mental health diagnoses should be “multi-axial.” The first axis is the “usual” diagnosis like Post-Traumatic Stress Disorder, major depression, or schizophrenia. The second
Page 7
October 13, 2009
VHA HANDBOOK 1601E.01
5
action indicates any associated personality disorders. The third axis indicates any associated general medical conditions. The fourth axis indicates the level of stress. The fifth axis indicates current functioning.
(10) Answers to any questions specifically requested in the examination request.
(11) Opinions specifically requested in the examination request, including specific evidence reviewed and considered in formulating the opinion, a thorough rationale for the opinion rendered, and expressed using legally-recognized phrases.
(12) A diagnosis or notation that a chronic disease or disability was ruled out for each
disability, complaint or symptom listed on the examination request.
(13) The clinic findings required by the rating schedule for the evaluation of the specific disability being claimed.
NOTE: Disability examination worksheets contain specific instructions of elements that must be addressed during the examination. Disability examination worksheets are available at:
http://vbaw.vba.va.gov/b1/21/rating/rat00.htm.

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