~ November 2022 ~

How to explain a change in diagnosis

In the Diagnosis section – select "Has changed and it is a..."

• This will open a sub-section that will allow you to select whether there is a progression, a new and separate diagnosis, or other.

• In the rationale text box, provide an explanation as to why the diagnosis was changed. CLEARLY state if the VA established diagnosis remains or is being replaced by the change and explain the reason for the change.

• If the change is due to a correction of a prior erroneous diagnosis, the explanation must be supported by the clinical evidence of record that refutes the previous exam(s) which diagnosed the condition.

• Review the non-editable grey boxes below your rationale to validate your response. Edits can only be made in the diagnosis section.

Example 1

VA established of Left Knee Strain with a newly rendered diagnosis of Degenerative Joint Disease with Instability

Progression: For the VA established diagnosis of left knee strain, the diagnosis is changed and it is a progression. Current x-rays show degenerative changes in the knee. Additionally, there was lateral instability on exam. This represents a progression of the prior condition.

Example 2

VA established diagnosis of Right Foot Plantar Fasciitis with a newly rendered diagnosis of Right Foot Plantar Fasciitis and Morton's Neuroma

New and separate diagnosis: For the VA established diagnosis of right foot plantar fasciitis, the diagnosis is changed and it is a new and separate diagnosis. Neuroma formation is an anatomical condition where the metatarsal heads are too close together or are forced into a position that entrap the nerve. Plantar fasciitis is a soft tissue condition where the ligament that connects the heel and metatarsal heads get stressed/stretched. The two are unrelated and separate. The plantar fasciitis is unchanged and is currently active based on exam.

Example 3

VA established diagnosis of Right Leg Injury, Other with a newly rendered diagnosis of S/P Fasciotomy with Scar Secondary to Compartment Syndrome

Other: For the VA established diagnosis of right leg injury, other, the diagnosis is changed and it is an update of prior diagnosis. Claimant had fasciotomy at the time of the leg injury and the change to diagnosis is an update since the surgery occurred immediately after injury, and therefore not a progression.

The Pact Act

The bill known as the Promise to Address Comprehensive Toxics (PACT) Act was signed into law by President Biden on 8/10/2022. This action will dramatically expand the benefits and services for veterans with toxic exposures and veterans of the Vietnam, Gulf War and post-9/11 eras who may develop injuries and illnesses that take years to manifest themselves. Those realities often made it difficult for veterans to establish a connection between their service and disabilities, preventing them from getting the care they needed. 

The Impact to QTC Examiners:

• Dramatic increase in toxic exposure claims due to the expansion of eligibility requirements for Gulf War and post 9/11 Veterans. This increase is anticipated in Focused exams to evaluate for current disability level.

• Adds more than 20 new presumptive conditions for burn pits and other toxic exposures.

• Adds more presumptive-exposure locations for Agent Orange and radiation

• VA adjudicators cannot make any PACT Act related rating decisions until January 2023. However, you may start to see some PACT Act related claims which VA will hold for adjudication until Congress has made funding available.

In Preparation:

Completion of the new VA required course, VA MDE Course, Assessing Deployment Related Environmental Exposures, has been required for ALL C&P Examiners to be knowledgeable about the basic principles of deployment related environmental exposure with a focus on using risk communication as a tool to improve education, information sharing, patient/provider satisfaction and foster behavior change that is most consistent with improving the health of Veterans with exposure concerns. See VA VBA MDE TRAIN Course 1101919 if you haven’t yet completed this course.

QTC will provide more information and additional guidance as received by the VA.

Learn more:

Gulf War Exposures - Public Health (va.gov)

 Environmental Exposures Basics

Have additional questions? 

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ACE VS In-Person

Based on a recent review of the quality errors, it was noted that a large percent of errors were due to the following:

• Both in-person and ACE were selected;

• Inconsistent selection between the Primary or Exam DBQ (i.e., In-Person) and the associated Medical Opinion DBQ (i.e., ACE); or

• No selection was made on the DBQ

 Important reminder: An exam cannot be both In-Person and ACE. Effective immediately, QAs have been authorized to correct this type of error on report and return to examiners for review/approval and a new signature.