General
1. Unanswered questions in the DBQs.
2. Not doing a thorough or adequate record review. Many reports are returned to point out that a provider’s medical opinion contradicts evidence in the veteran’s records.
3.
Diagnosing arthritis without radiographic
evidence.
4. Not providing a diagnosis when there are objective findings in an exam. A diagnosis must be rendered based on the objective findings; otherwise, VA will need an explanation on why no diagnosis is possible.
5. Not addressing each of the veteran’s claimed conditions. If there is no diagnosis, then the provider should state the reason why.
6. Changing
a veteran’s service connected diagnosis without providing an explanation, i.e.
whether the new diagnosis is a progression of the previous diagnosis, the
development of a new and separate condition, or a correction of the previous
diagnosis. Note – increased symptoms of the same diagnosis do not constitute
a progression.
7. Inconsistencies. Some examples:
a. Medical records review marked “yes” on one DBQ and “no” on another.
b.
Noting in question 3D in a joint DBQ
that the exam IS being conducted during a flare up; however, when asked how
pain/fatigue/weakness would affect the ROMs stating “unable to replicate.”
c. Not matching up diagnosis dates across DBQs.
8. Not addressing diagnostic results in the DBQ.
9. Not following DBQ instructions. The most common DBQ instruction ignored by providers is the need to add other DBQs triggered by symptoms/complications of a veteran’s condition.
10. Not answering the entire question. Ex. – When multiple scars are diagnosed many providers don’t answer this question fully: Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful).
11. Not addressing a diagnosed condition in the “other” section when it did not fit anywhere else.
Example (this occurs on many other DBQs too): Provider diagnoses dry eye syndrome and does not feel it falls into any of these specific categories. It must then instead be addressed under “other”:
Does the Veteran have any of the
following eye conditions?
[]
Yes [X] No
If no, proceed to Section V.
If yes, check all that apply:
|
[] Anatomical loss
of eyelids, and/or brows
|
(If checked, complete Item 2 below) |
|
[] Lacrimal gland
and lid disorders (other than ptosis or anatomic loss) |
(If checked, complete Item 3 below) |
|
[] Ptosis, for either or
both eyelids
|
(If checked, complete Item 4 below) |
|
[]
Conjunctivitis and other conjunctival conditions
|
(If checked, complete Item 5 below) |
|
[] Corneal
conditions
|
(If checked, complete Item 6 below) |
|
[] Cataract and other
lens conditions
|
(If checked, complete Item 7 below) |
|
[] Inflammatory eye
conditions and/or injuries
|
(If checked, complete Item 8 below) |
|
[] Glaucoma
|
(If checked, complete Item 9 below) |
|
[] Optic neuropathy
and other disc conditions
|
(If checked, complete Item 10 below) |
|
[] Retinal
conditions
|
(If checked, complete Item 11 below) |
|
[] Neurologic eye
conditions
|
(If checked, complete Item 12 below) |
|
[] Tumors and
neoplasms
|
(If checked, complete Item 13 below) |
|
[] Other eye
condition(s)
|
(If checked, complete Item 14 below) |
12. Not matching up onset dates for a condition across various sections of the DBQ.
13. Diagnosing symptoms.
14. Not retaining service connected diagnoses when the veteran reports continued symptoms.
15. Checking off “yes” for the Functional Impairment question when there is no diagnosis.
Audio
1. Not performing a Stenger test when there is a difference of 20 or more at .5-4k.
2.
Not providing evidence that pre-existing hearing
loss was aggravated by service.
3.
Opining on significant threshold shifts in the
absence of audiograms from the service records.
4.
Not opining on the relationship between tinnitus
and military service.
5. Not diagnosing hearing loss although CNC results are 92% or below.
6. Opining that hearing loss is both secondary to military service and aggravated by it.
Diabetes
1. Diagnosing diabetes when the veteran is not on any medication and the current fasting bloodwork is within normal limits.
2. Not addressing signs of nephropathy on current lab work with either a diagnosis and Kidney DBQ or explanation.
3. Finding
that HTN is secondary to Diabetes when there is no renal involvement.
4. Stating
that complications of diabetes are both secondary to Diabetes and aggravated by
it.
Foot
1. Not answering this question when pain is noted in the history section but was not noted on physical exam:
Is there pain on physical exam?
[]
Yes [X] No
If no, but the Veteran reported pain in his/her
medical history, please provide rationale below.
Gen Med 1016
1. Not completing all DBQs that are checked off for conditions found on the Gen Med 1016 DBQ.
2. Not checking off all conditions found that have accompanying DBQs.
Joints
1. Checking off “normal” for abnormal ROMs.
2. Answering the below question in the joint DBQs incorrectly. Example of what not to do:
If abnormal, does the range of motion itself
contribute to a functional loss?
[X] Yes [] No
If yes, please explain:
|
He has pain on flexion |
VA is asking about the ROM itself, not any associated pain. For instance, if there is a limitation in knee flexion does that motion loss itself affect their ability to bend or squat?
3. Diagnosing or checking off ankylosis when the veteran has any range of motion at all in the joint.
Mental/PTSD
1. Not ensuring that all questions from the bottom of the Mental DBQ are answered when a PTSD DBQ is needed instead.
2. Checking off one of the below options when there is no diagnosis of PTSD.
Criterion I: Which stressor(s) contributed to the Veterans PTSD diagnosis?
[X] Stressor #1
[] Stressor #2
[] Stressor #3
[] Stressor #4
3. Not addressing all of the appropriate questions under specific stressors for PTSD:
o Does
this stressor meet Criterion A (i.e., is it adequate to support the diagnosis
of PTSD)?
o Is
the stressor related to the Veteran’s fear of hostile military or terrorist
activity?
o Is
the stressor related to in-service personal assault, e.g. military sexual
trauma?
4. Not answering this question when a diagnosis other than PTSD is given in addition to or in place of PTSD:
Please state if the veteran's PTSD is at least as
likely as not due to or was incurred in the veteran’s military service. If a
diagnosis other than PTSD is rendered, please state if this mental disorder is
at least as likely as not due to or was incurred in the veteran’s military
service.
Medical Opinion (MO) DBQ
1. Not citing evidence from the medical records for sections 4, 6, and 8 in support of your opinion, whether positive and negative.
2. Checking the wrong option (A vs B) under each section 4-7. For example: a positive opinion (4a) given with a negative rationale, or a negative opinion (4b) was given with a positive rationale.
Radiculopathy/IVDS/Peripheral Nerve
1. Diagnosing IVDS/Radiculopathy/peripheral neuropathy without objective evidence (abnormal strength, reflexes, or sensory testing).
2. Not matching up findings across DBQs that have redundant sections such as sensory testing, muscle strengths, or reflexes.
Respiratory
1. Not
diagnosing a condition when the PFT or CXR are abnormal.
2. Answering
“unknown” to this question:
g. If
diffusion capacity of the lung for carbon monoxide by the single breath method
(DLCO) testing has not been completed, provide reason:
[]
Not indicated for Veteran’s condition
[]
Not indicated in Veteran’s particular case
[]
Not valid for Veteran’s particular case
[X] Other,
describe:
|
Unknown |
Scar
1. Not answering all questions on the scar DBQ, if applicable. Example – the section for the trunk and extremities is completed, but these are left blank:
e. Anterior trunk
[] Affected [] Not affected
f. Posterior trunk
[] Affected [] Not affected
2-2. Summary of
nonlinear scar areas for the trunk and extremities
2. Not
providing the surface area involved when you must use “TNTC” (too numerous to
count).
TBI
1. Diagnosing TBI without AOC, LOC or combat action ribbon noted in medical records.
2. Checking off symptoms of a TBI in the “Residuals of TBI” section when there is no diagnosis of TBI.