Traumatic Brain Injury (TBI)

Topics:

Traumatic Brain Injury
TBI Rating System
Rating Cognitive Conditions and Symptoms
Rating Physical Conditions and Symptoms
Rating Emotional and Behavioral Conditions and Symptoms
TBI Residuals Rating Table
Common Conditions and Symptoms caused by TBI
Examples of Rating TBI
Principles that Apply

Reminder: The VA will give a Military Disability Rating for each service-connected condition a service member has, but the DoD will only rate service-connected conditions that make a service member Unfit for Duty.

Note: The TBI ratings were updated on October 23, 2008. If your TBI was rated before that date, you can request for the VA to review your condition and update your rating based on the new rating requirements. The VA will then conduct new examinations and rate the condition under the new ratings. The VA will not lower the rating UNLESS the condition has obviously improved. If the condition is the same or worse, then the rating will either remain the same or be raised under the new rating criteria. If the VA does raise your rating, the benefits from the higher rating will be post-dated to October 23, 2008.

Note II: The VA gives extra compensation for the loss or loss of use of a body part or organ. If your TBI causes the loss or loss of use of a body part or organ, visit the Special Monthly Compensation page to see if it qualifies for additional compensation.

Rating TBI is difficult. Very difficult. So a disclaimer is in order: All we can do is help you guess how the Rating Authorities will rate your condition. We can only guide you so far, so when trying to decide which code is best for a particular condition or symptom, make sure to read all the information on the condition, including how it is rated so that you can make a better educated guess about which code resembles your condition the best.

Remember, however, that it is the Rating Authorities who ultimately choose how a condition is rated. The principles discussed on this page are used by the Rating Authorities, but the various Authorities may interpret or apply these principles differently. Because of that, it is impossible to predict how the Rating Authorities will rate your TBI condition. The best we can do is explain the principles to you. Probably the best way our discussion about TBI can help you is by giving you an understanding of the tests needed and information necessary to properly rate your condition. With this knowledge, make sure that all the proper tests are performed, thorough notes are taken by the physician, and the necessary conditions are officially diagnosed so that when the Rating Authorities apply these principles, they will have a complete record of every facet of your condition.

 


Traumatic Brain Injury (TBI)

Traumatic brain injury (TBI) is a condition where the brain is damaged because of a traumatic event. A “traumatic event” is any event, like a car accident, IED blast, gunshot wound, falling and hitting your head, etc., that causes damage to the brain.

If the brain condition is caused by an illness or is genetic, then it is not considered TBI and cannot be rated here. Please see The Central Nervous System page for conditions of the brain and nerves or the Mental Disorders page for psychiatric conditions.

Similarly, there may be other conditions that occur at the same time as the TBI. These conditions could include skin burns, exposure to toxic substances, amputations, etc. Since these conditions are not directly caused by the trauma to the brain, they are not rated here but are rated separately.

Some individuals experience numerous TBIs—they could be exposed to repeated IED blasts, etc. Regardless of how many incidences are experienced, the overall brain condition caused by all the TBIs is rated as a single condition.

The brain is protected by layers of soft tissue and a liquid called cerebrospinal fluid. The fluid and tissues act as a bumper between the brain and the skull. The cerebrospinal fluid also acts as an electrical conduit between the different parts of the brain and nerves, and it carries nutrients from the blood to the brain. If the TBI causes tears in the soft tissues surrounding the brain, this liquid can leak out, disrupting brain function. TBI can also cause the fluid to build up in certain areas, causing increased pressure on that area of the brain (“hydrocephalus”). Likewise, TBI can cause blocks in the blood-flow or hemorrhaging, which can deprive the brain of the essential nutrients it needs to function. If the blood is unable to take its nutrients to the brain for 4 minutes or longer, damage to the brain cells becomes permanent. Infections (like meningitis) can also result from TBI and cause damage to the tissues of the brain.

The brain controls every single function in the entire body, whether it be involuntary (beating the heart, digesting food, etc.), voluntary (moving the arm, speaking, etc.), or cognitive (thinking, problem solving, making decisions, etc.). Each function is controlled by a different part of the brain, so damage caused by TBI can affect one, many, or all functions of the body. Because of the vast amount of damages that can occur, each case of TBI is very individual and unique. This makes rating a TBI condition rather complicated, but we’ll try to make it a little more manageable.

Because damage to the brain can affect any bodily function, it is essential that each function that is impaired is properly examined. So, if the condition affects the ability to see, thorough examinations must be done on the eyes in order to properly rate the TBI. This goes for every symptom that is present. Examinations do not have to be done on a certain bodily function, however, if there are no clear symptoms to suggest that it has been affected. Similarly, it is essential that the physician fully notes how the condition and all its symptoms affects the individual’s ability to function in necessary daily activities, like cleaning and cooking, self-care, and occupational tasks. Does the condition interfere with the individual’s ability to work? Can he bathe himself and use the restroom? In addition to this, in many TBI cases, the individual affected may not be able to properly tell the history of his condition and describe all its symptoms to the physicians. It is important in these cases that a third party who is familiar with the entire condition, like a family member, is able to attend all examinations so that everything is properly recorded.

A symptom can only be rated under TBI if it is directly caused by TBI. If a physician does not note in his records that a symptom was caused by TBI, then it cannot be rated here. This includes symptoms and conditions that may develop in the future. Since TBI can affect so many parts of the body, many conditions caused by TBI may not develop until much later. These can only be rated if there is enough solid evidence to prove that they were directly caused by the TBI that occured while you were in the military, and not by any other logical cause.

In January 2014, the VA changed their regulations on rating TBI to plainly state that a few conditions which may not develop until later will always be assumed to have been caused by TBI, and thus are eligible for disability compensation from the VA as soon as they develop, with a few caveats. These conditions include Parkinsonism, Parkinson's disease, seizures, dementia, depression, and some hormone deficiency diseases. If you have one or more of these conditions, see if it qualifies to be rated under TBI.

Now, immediately after the trauma occurs, the physician will diagnose the severity of the trauma: mild, moderate, or severe. These diagnoses are ONLY for the severity of the initial trauma itself. The severity of the initial trauma and the severity of the lasting symptoms are often very close, but not always. While rare, a person could have severe initial trauma and only mild lasting symptoms. Because of this, the diagnosis of the severity of the initial trauma cannot be used for rating. A rating can only be made on the severity of the resulting conditions and symptoms themselves. More will be said on this under the TBI Rating System below.

There are also several scales that you might find on your medical reports that are used to determine the initial severity of the trauma: the Glasgow Coma Scale (GCS) and the Rancho Los Amigos Scale are some examples of these scales. Physicians may also determine the initial severity of the trauma by how long the individual is unconscious or, if there is any amnesia, how long it lasts. All of these things are only used to determine the initial severity of the trauma and are not used to rate the condition. Just ignore them when rating TBI.

Similarly, the physician might refer to an individual’s condition as Post-Concussion Syndrome (PCS) on the report. This is just a generic term that refers to any group of conditions and symptoms caused by TBI. This term is not important to rating. Ignore it as well.

The symptoms/conditions caused by TBI can last a few days or weeks to a few years or permanently. It is hard to predict just how long the symptoms may last. The majority of symptoms in the majority of cases of mild TBI resolve within the first three months following the trauma. Only between 10-20% of mild cases have symptoms that last one year or more. The majority of symptoms of moderate TBI resolve, or at least improve significantly, in the first 6 months after the trauma. With severe TBI, it is impossible to really predict how long the symptoms will last or improve, if at all. Because of this uncertainty, the condition is simply rated on the severity of the symptoms at the time of examination (for DoD, this would be the examination closest to the date of separation).

There are three kinds of conditions and symptoms that can be caused by TBI: cognitive, physical, and emotional/behavioral. Cognitive conditions interfere with the ability of the brain itself to function properly. They can affect the brain’s ability to process information, reason, problem-solve, make decisions, organize, prioritize, etc. Physical conditions deal with the ability of the body to function. Emotional and behavioral conditions address psychological health, like depression, hallucinations, etc.

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TBI Rating System

TBI is rated on the symptoms/conditions that it causes. To try and make TBI rating more manageable, we will first discuss the basic principles behind rating TBI. Then we will discuss how to rate the various kinds of conditions/symptoms as well as give lists of the most common conditions and symptoms caused by TBI. We will end with detailed examples of how to rate TBI without getting overwhelmed. There will be a lot of information up front, but hang in there. Hopefully the examples will help make it easier.

First, the code. There is only one code for TBI:

Code 8045: Residuals of traumatic brain injury.

“Residuals” refers to all the symptoms and bodily functions that are affected because of TBI. TBI is not given a single rating, but is rated on the severity of all the conditions and symptoms that it causes.

There are two different kinds of ratings that are given for TBI. The first is any condition that has been officially diagnosed by a qualified physician (“qualified” means that they are the appropriate type of physician for the condition—i.e. a psychologist for a mental illness, ophthalmologist for vision problems, etc.). There can be as many ratings as there are diagnosed conditions. So if there are 4 diagnosed conditions that are caused by TBI, then there can be 4 ratings, one for each. The second kind of rating that is given for TBI is a single rating for all the other symptoms that are not officially diagnosed as distinct conditions. These are all given one rating based on the TBI Residuals Rating Table, discussed below.

A condition or symptom can only be rated separately under its own code if there is a definite diagnosis. In other words, headaches alone cannot be rated separately, but a definite diagnosis of migraine headaches can. Just being depressed is not enough to rate it as depression, but a definite diagnosis of Major Depressive Disorder can. Got it? The physician must diagnose an actual condition for a condition or symptom caused by TBI to be separately ratable.

So, for every TBI case, one rating is given for each diagnosed condition and one more communal rating is given for the remaining symptoms based on the TBI Residuals Rating Table.

VERY important: A single symptom cannot be rated twice. So if it is a major part of another condition that is rated, then it cannot have its own rating or be rated again under another ratable condition. For example, migraine headaches can cause vomiting. If the vomiting only occurs when there is a migraine headache, then the rating for migraine headaches covers the vomiting. Vomiting cannot then be used to rate another condition, be figured into the communal rating under the TBI Residuals Rating Table, or be rated on its own since it has already been rated. If there are two diagnosed conditions that cause the same symptoms, then only one of those conditions can be rated—the one that describes the overall condition best. The basic rule is very important: a symptom cannot be rated twice.

To organize the multitude of symptoms and conditions that are caused by TBI, let’s start by dividing them into three stages. The first stage is the TBI itself. The second stage is the large-scale conditions like stroke, infection, leakage of the cerebrospinal fluid, mental disorders, nerve damage, etc. In Stage 3 are the symptoms, like decreased vision, nausea, headaches, paralysis, etc., that are caused by the Stage 2 conditions or result from the Stage 1 TBI but do not fall under a specific Stage 2 condition. See the following table to visualize this:

Stage 1

Traumatic Brain Injury

Stage 2

Stroke

Infection

Dementia

Seizures

Other

Stage 3

Arm Paralysis

Decreased Vision

Dizziness

Can’t Speak

Hallucinations

Memory Loss

Headaches

Etc.


If a Stage 2 condition is officially diagnosed, and is thus ratable, then any Stage 3 symptoms it causes cannot be rated separately. Only one rating is given for the entire condition and all its symptoms. For example, using the chart above, if dementia was diagnosed by a physician, it is ratable, but hallucinations and memory loss are not since they are caused by the dementia. Stage 2 conditions take rating precedence over Stage 3 symptoms. As long as a Stage 2 condition is diagnosed, it must be rated, and so its symptoms, even if they also have definite diagnoses, are not. You can’t rate two Stage 3 symptoms instead of rating just one Stage 2 condition. It sounds like a great way to get more ratings, but it’s not allowed. Sorry.

If, however, a Stage 2 condition does not have a definite diagnosis or if there is no Stage 2 condition connecting the symptom to the TBI (as is the case with seizures in the table above), then the Stage 3 symptoms CAN each be rated under their own codes as long as they have definite diagnoses.

If a condition or symptom has a definite diagnosis, but the VASRD does not have a code for it, rate it under the code that best describes the overall condition. For example, low blood pressure can be caused by damaged nerves in the brain. The most common symptoms of low blood pressure are dizziness and lightheadedness. The VASRD doesn’t have a code for low blood pressure, so, if it is definitely diagnosed, it can either be rated as atrioventricular block under code 7015 or as a peripheral vestibular disorder under code 6204, whichever best matches the exact symptoms. This is when rating TBI gets very complicated. Either of these codes can work for low blood pressure, and it may be difficult to know where to look to find the most appropriate code. Unfortunately, we can’t do more than say just do the best you can. It is strictly up to the Rating Authorities to pick the one they think best defines the diagnosed condition. We try to cover the most common TBI conditions and symptoms in our list below and how they could be rated, but unfortunately we can’t come close to covering every possibility.

Reminder: a single symptom cannot be used twice. So, if it is covered by one code, it cannot be used to support a second code, even if two separate conditions are diagnosed. This is especially the case for mental disorder symptoms and cognitive symptoms. Often these categories share the same symptoms. If this is the case, only one rating can be given under the code that most closely resembles the overall condition. Sometimes, however, two separate diagnosed conditions will both have their own separate symptoms with only one or two in common. If both separate conditions have enough of their own symptoms to support a rating without the shared symptoms, then both can still be rated. This principle is one of those that cannot be specifically defined. What exactly are “enough” symptoms to support a rating? The only guidance we can really give on this is to thoroughly read all the requirements for rating a certain condition. If these requirements are fulfilled without the shared symptoms, then it can be rated. Ultimately, this decision is left up to the interpretation of the Rating Authorities.

Each diagnosed condition caused by TBI that is rated under its own separate code will have two hyphenated codes like this: 8045-8100. The first four-digit code defines the cause of the condition as TBI, and the second four-digit code defines the diagnosed condition and how it is rated. In this example, the condition would be rated as migraine headaches (code 8100) caused by TBI (code 8045).

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Rating Cognitive Conditions and Symptoms

Cognitive conditions/symptoms interfere with the ability of the brain itself to function properly, including processing information, making decisions, reasoning, etc.

Quite often, symptoms caused by a cognitive condition can also be caused by a physical or psychological condition. For example, if a nerve is damaged, an individual could lose the ability to speak since the physical muscles are unable to properly perform the motions necessary to speak, a physical condition. A person might also not be able to speak, not because the body doesn’t work, but because the mind is unable to understand and process language enough to speak, a cognitive condition. It is important that the correct cause of symptoms is known in order to properly rate them. Remember that a single symptom can only be rated once, even if more than one diagnosed condition is present.

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Rating Physical Conditions and Symptoms

The majority of physical symptoms of TBI are caused by the nerves being damaged or the brain’s ability to communicate with the nerves being disrupted. Because of this, the majority of physical symptoms will not be separately rated since only one rating will be given for the entire damaged nerve and all its symptoms. It can be a bit difficult to determine which nerve is causing each symptom since often more than one nerve might affect the same function.

The examining physicians should make clear notes about which nerves have been damaged. If this information is not in the reports, choose the one that seems closest to the overall condition. If two nerves are clearly damaged but both only cause the same symptoms, then only one can be rated since symptoms cannot be rated twice. The function of each nerve and its ratings is discussed on The Central Nervous System page. Not every nerve is given its own ratings. If the nerve is not on The Central Nervous System page or the corresponding nerve pages, then rate the symptoms directly. For example, the optic nerve is not rated by the VASRD, so any damage to the optic nerve is rated on the decrease in eyesight that it causes.

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Rating Emotional and Behavioral Conditions and Symptoms

Emotional and behavioral Stage 2 conditions are psychological (mental) disorders like Major Depressive Disorder, Post-Traumatic Stress Disorder (PTSD), Dementia, etc. Psychological Stage 3 symptoms can include things like anger, irritability, nightmares, anxiety, depression, and many more. If a mental disorder is officially diagnosed by a psychiatrist or psychologist, then only one rating is given for the condition and all its symptoms. See the Mental Disorders page for information on rating diagnosed mental disorders. Remember that if a condition is diagnosed but is not listed on the Mental Disorders page, choose the code that most closely defines the condition.

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TBI Residuals Rating Table

Any remaining symptoms that are not officially diagnosed are used together to make one more rating for TBI based on the TBI Residuals Rating Table. This last rating is simply coded 8045, residuals of traumatic brain injury.

Here are a few definitions that will help with this rating:

– Self-care is the ability to perform all the basic necessary activities of life, including bathing, dressing, eating, getting in and out of bed, and using the toilet.
– Daily living consists of all the activities beyond self-care that are essential for independent living, including cooking, doing chores, shopping, traveling, doing laundry, cleaning, being responsible for medications, and using the telephone.
– Mild refers to how the condition affects the ability to hold a job, perform work duties, develop and maintain personal relationships, and perform tasks of self-care and daily living. A mild impairment would mean that you are only rarely and mildly unable to function in these areas. It could be forgetting appointments, taking longer to complete tasks, etc. A person with a mild condition would still be able to hold a job and function completely fine the majority of the time.
– Moderate means that you are regularly unable to function in these areas. A person with a moderate condition would be able to get a job, but probably wouldn’t be able to hold it for long. Relationships might be present, but rocky.
– Severe means that you are completely unable to function in these areas. Constant supervision would be needed in order to maintain self-care.

How to use the table: There are 10 categories in the table.

Step 1: First, sort each symptom into one of these categories.

Step 2: Next, look at all the symptoms in a single category and assign a level of impairment for that category based on the criteria for each level. (Remember, you are looking at all the symptoms in that category together. If one symptom only troubles you once a week, and another troubles you twice a week, then the symptoms cause problems 3 days a week.) If there are no symptoms in a category, that category is assigned a level of impairment of 0.

Step 3: Once each category has a level of impairment, determine which has the highest level of impairment.

Step 4: The highest level is then translated into the final rating for these remaining symptoms using this table.

Level of Impairment Equivalent Ratings

0

0%

1

10%

2

40%

3

70%

Total

100%

 

So, if the highest level is 2, the final overall rating is 40%. This would then be the final rating for these extra symptoms. Only the 1 rating is given for all these symptoms, no matter how many there are.

TBI Residuals Rating Table

Category

Level of Impairment

Criteria

Executive Functions (memory, attention, concentration, goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, spontaneity, and flexibility)

0

No problems.

1

Very Mild—trouble with one or more of the executive functions causes occasional minor problems like trouble remembering names, following conversations, misplacing items, etc., but overall functioning is fine. There is no evidence of these problems when tested.

2

Mild—trouble with one or more executive functions causes occasional minor problems, but overall functioning is fine. There IS evidence of these problems when tested.

3

Moderate—trouble with one or more executive functions causes fairly regular problems that interfere with the ability to work and care for self.

Total

Severe—trouble with one or more executive functions causes the complete inability to work and care for self.

 

Judgment
(the ability to identify and understand issues, consider alternatives, comprehend consequences of choices, and make reasonable decisions)

0

Normal.

1

Mild—occasional slight trouble understanding and making complex, significant decisions. Overall ability to function normally.

2

Moderate—regular trouble understanding and making complex, significant decisions, but no trouble with simple, familiar decisions.

3

Moderately Severe—occasional trouble understanding and making any reasonable decision. For example, unable to choose appropriate clothing for the weather.

Total

Severe—almost always unable to understand and make reasonable decisions.

 

Social Interaction
(the ability to interact with other people in an acceptable and appropriate manner, i.e. responding appropriately to other’s moods or circumstances, ablptable limits, etc.)

0

Interaction is always appropriate.

1

Interaction is occasionally inappropriate.

2

Interaction is frequently inappropriate.

3

Interaction is always or almost always inappropriate.

 

Orientation
(the abilite to keep physical contact in accey to identify

1. Person
2. Time
3. Situation
4. Place

—i.e. who you are, who you’re with, where you are, what you’re doing, what day it is, what time it is, etc.)

0

Always oriented.

1

Occasionally unable to identify one of the four.

2

Occasionally unable to identify two of the four or regularly unable to identify one of the four.

3

Regularly unable to identify two or more.

Total

Always or almost always unable to identify two or more.

 

Motor Activity
(the ability to perform precise learned movements and tasks, like playing an instrument, writing, etc. Symptoms only fall under this category if the nervous system/muscles that control these motions are not damaged. In other words, the only cause of the symptoms in this category is mental, not physical, known as “apraxia”)

0

Normal.

1

The ability to perform learned motor activities is occasionally, mildly decreased.

2

The ability is always mildly decreased or occasionally moderately decreased.

3

The ability is always moderately decreased.

Total

The ability is always seriously decreased—completely unable to perform these tasks.

 

Visual Spatial Orientation
(the ability to follow directions, not get lost, read maps, judge distance, use GPS devices, etc.)

0

Normal.

1

Mild—occasionally gets lost in unfamiliar areas, has trouble reading maps, following directions, judging distance, etc., but is always able to use GPS devices.

2

Moderate—always or almost always gets lost in unfamiliar areas, can’t read a map, follow directions, or judge distance. Has trouble using GPS devices.

3

Moderately Severe—always or almost always gets lost even in familiar areas. Can’t use GPS devices at all.

Total

Severe—completely unable to find the way from one room to another in a familiar place, unable to touch or name own body parts when asked, etc.

 

Neurobehavioral Effects
(These are symptoms that are based in emotional and mental health—examples include irritability, verbal and physical aggression, impulsivity, lack of empathy, unpredictability, lack of motivation, belligerence, apathy, moodiness, inflexibility, etc.)

0

None of the symptoms interfere with the ability to work or build relationships.

1

Symptoms occasionally interfere with the ability to work or build relationships.

2

Symptoms often interfere with the ability to work or build relationships.

3

Symptoms make it impossible to hold a job or build and maintain steady relationships, or supervision is occasionally required for the safety of self and others.

 

Communication
(the ability to communicate and understand both spoken and written words)

0

Fully capable of communication by both spoken and written words.

1

Occasional trouble communicating by spoken or written words.

2

Trouble communicating or understanding spoken or written words regularly but less than 50% of the time. Is still mostly able to communicate complex ideas.

3

Trouble communicating or understanding spoken or written words at least 50% of the time. Can communicate basic needs, but may need to use gestures to help communicate.

Total

Complete inability to communicate or understand spoken or written words. Cannot communicate basic needs at all.

 

Consciousness
(literally, whether or not you are conscious or in a coma or vegetative state)

0

Fully conscious.

Total

In a vegetative state, coma, or other altered state of consciousness.

 

Subjective Symptoms
(all symptoms that do not fit into the other categories are put in this one—examples include headaches, anxiety, dizziness, ringing in the ears, insomnia, hypersensitivity to light or sound, fatigue, blurred vision, double vision, etc.)

0

One or two symptoms interfere with daily living, self-care, work duties, or relationships.

1

Mild—three or more symptoms occasionally interfere with daily living, self-care, work duties or relationships.

2

Moderate—three or more symptoms regularly interfere with daily living, self-care, work duties or relationships.


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Let’s do an example of how to use this table. Just for the purpose of this example, let’s say that a service member has all of the following symptoms. None are diagnosed (can’t be separately rated), and none are covered by other ratable conditions.

Memory loss – has trouble remembering conversations or directions at least once a day. A neuropsychological test showed that there was definite impairment in this area.
Occasionally forgets entirely how to play his guitar (which he’s played since a child)
In the morning, he often thinks it is the end of the day instead of the beginning
Almost always gets lost in unfamiliar places—has significant trouble using a map
Loses his temper easily
Gets into fights regularly over trivial things
Often grumpy or irritable
About once or twice a month, he has trouble understanding things he is reading
Headaches once or twice a week which require him to stop his activities and rest
Resistant to any unexpected change in plans or circumstances. A neuropsychological test showed that there was definite impairment in this area.
About once a week, he lacks proper judgment, like deciding to walk to a store 15 miles away because the weather is nice
Regularly says rude or inappropriate things
Has trouble sleeping at least once a week

Now that we have our list of symptoms, let’s figure out which category each one fits.

Category

Level of Impairment

Criteria

Executive Functions (memory, attention, concentration, goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, spontaneity, and flexibility)
– Memory loss: has trouble remembering conversations or directions at least once a day. Tested positive.
– Resistant to any unexpected change in plans or circumstances (lack of spontaneity) Tested positive.

0

No problems.

1

Very Mild—trouble with one or more of the executive functions causes occasional minor problems like trouble remembering names, following conversations, misplacing items, etc., but overall functioning is fine. There is no evidence of these problems when tested.

2

Mild—trouble with one or more executive functions causes occasional minor problems, but overall functioning is fine. There IS evidence of these problems when tested.

3

Moderate—trouble with one or more executive functions causes fairly regular problems that interfere with the ability to work and care for self.

Total

Severe—trouble with one or more executive functions causes the complete inability to work and care for self.

 

Judgment
(the ability to identify and understand issues, consider alternatives, comprehend consequences of choices, and make reasonable decisions)
– About once a week, he lacks proper judgment, like deciding to walk to a store 15 miles away because the weather is nice

0

Normal.

1

Mild—occasional slight trouble understanding and making complex, significant decisions. Overall ability to function normally.

2

Moderate—regular trouble understanding and making complex, significant decisions, but no trouble with simple, familiar decisions.

3

Moderately Severe—occasional trouble understanding and making any reasonable decision. For example, unable to choose appropriate clothing for the weather.

Total

Severe—almost always unable to understand and make reasonable decisions.

 

Social Interaction
(the ability to interact with other people in an acceptable and appropriate manner, i.e. responding appropriately to other’s moods or circumstances, able to keep physical contact in acceptable limits, etc.)
– Regularly says rude or inappropriate things

0

Interaction is always appropriate.

1

Interaction is occasionally inappropriate.

2

Interaction is frequently inappropriate.

3

Interaction is always or almost always inappropriate.

 

Orientation
(the ability to identify
1. person
2. time
3. situation
4. place
—i.e. who you are, who you’re with, where you are, what you’re doing, what day it is, what time it is, etc.)
– In the morning, he often thinks it is the end of the day

0

Always oriented.

1

Occasionally unable to identify one of the four.

2

Occasionally unable to identify two of the four or regularly unable to identify one of the four.

3

Regularly unable to identify two or more.

Total

Always or almost always unable to identify two or more.

 

Motor Activity
(the ability to perform precise learned movements and tasks, like playing an instrument, writing, etc. Symptoms only fall under this category if the nervous system/muscles that control these motions are not damaged. In other words, the only cause of the symptoms in this category is mental, not physical, known as “apraxia”)
– Occasionally forgets entirely how to play his guitar (which he’s played since a child)

0

Normal.

1

The ability to perform learned motor activities is occasionally, mildly decreased.

2

The ability is always mildly decreased or occasionally moderately decreased.

3

The ability is always moderately decreased.

Total

The ability is always seriously decreased—completely unable to perform these tasks.

 

Visual Spatial Orientation
(the ability to follow directions, not get lost, read maps, judge distance, use GPS devices, etc.)
– Almost always gets lost in unfamiliar places—has significant trouble using a map

0

Normal.

1

Mild—occasionally gets lost in unfamiliar areas, has trouble reading maps, following directions, judging distance, etc., but is always able to use GPS devices.

2

Moderate—always or almost always gets lost in unfamiliar areas, can’t read a map, follow directions, or judge distance. Has trouble using GPS devices.

3

Moderately Severe—always or almost always gets lost even in familiar areas. Can’t use GPS devices at all.

Total

Severe—completely unable to find the way from one room to another in a familiar place, unable to touch or name own body parts when asked, etc.

 

Neurobehavioral Effects
(These are symptoms that are based in emotional and mental health—examples include irritability, verbal and physical aggression, impulsivity, lack of empathy, unpredictability, lack of motivation, belligerence, apathy, moodiness, inflexibility, etc.)
– Losses his temper easily
– Gets into fights regularly over trivial things
– Often grumpy or irritable

0

None of the symptoms interfere with the ability to work or build relationships.

1

Symptoms occasionally interfere with the ability to work or build relationships.

2

Symptoms often interfere with the ability to work or build relationships.

3

Symptoms make it impossible to hold a job or build and maintain steady relationships, or supervision is occasionally required for the safety of self and others.

 

Communication
(the ability to communicate and understand both spoken and written words)
– About once or twice a month, he has trouble understanding things he is reading

0

Fully capable of communication by both spoken and written words.

1

Occasional trouble communicating by spoken or written words.

2

Trouble communicating or understanding spoken or written words regularly but less than 50% of the time. Is still mostly able to communicate complex ideas.

3

Trouble communicating or understanding spoken or written words at least 50% of the time. Can communicate basic needs, but may need to use gestures to help communicate.

Total

Complete inability to communicate or understand spoken or written words. Cannot communicate basic needs at all.

 

Consciousness
(literally, whether or not you are conscious or in a coma or vegetative state)

0

Fully conscious.

Total

In a vegetative state, coma, or other altered state of consciousness.

 

Subjective Symptoms
(all symptoms that do not fit into the other categories are put in this one—examples include headaches, anxiety, dizziness, ringing in the ears, insomnia, hypersensitivity to light or sound, fatigue, blurred vision, double vision, etc.)
– Headaches once or twice a week which require him to stop his activities and rest
– Has trouble sleeping at least once a week

0

One or two symptoms interfere with daily living, self-care, work duties, or relationships.

1

Mild—three or more symptoms occasionally interfere with daily living, self-care, work duties or relationships.

2

Moderate—three or more symptoms regularly interfere with daily living, self-care, work duties or relationships.


Now we need to determine the Level of Impairment for each category.

Let’s start with Executive Functions. Remember, we need to determine the overall level for this category considering everything that is in it. Looking at the information we have for the symptoms, memory loss only once a day is a definite problem, but probably doesn’t keep him from functioning fairly well. The most logical level for that symptom would be 2 (supportable since he tested positive for impairment). The lack of spontaneity, however, is all the time, which would definitely affect his ability to function at work and in day-to-day activities, but probably not completely. A 3 would make the most sense for this symptom (also supportable since he tested positive for impairment). Taking the average of the two for the final level assignment is what should be done usually, but since 2 and 3 are right next to each other (there is nothing in between), use the higher level. So, the overall level for Executive Functions is 3.

Executive Functions
– Memory loss – has trouble remembering conversations or directions at least once a day.
– Resistant to any unexpected change in plans or circumstances (lack of spontaneity)

0

No problems.

1

Very Mild—trouble with one or more of the executive functions causes occasional minor problems like trouble remembering names, following conversations, misplacing items, etc., but overall functioning is fine. There is no evidence of these problems when tested.

2

Mild—trouble with one or more executive functions causes occasional minor problems, but overall functioning is fine. There IS evidence of these problems when tested.

3

Moderate—trouble with one or more executive functions causes fairly regular problems that interfere with the ability to work and care for self.

Total

Severe—trouble with one or more executive functions causes the complete inability to work and care for self.


Judgment. While his judgment is definitely impaired, it only occurs once a week. This can’t really be defined as “regular”. Regular would be the majority of the time. So, the best level for this category is 1.

Judgment
– About once a week, he lacks proper judgment, like deciding to walk to a store 15 miles away because the weather is nice

0

Normal.

1

Mild—occasional slight trouble understanding and making complex, significant decisions. Overall ability to function normally.

2

Moderate—regular trouble understanding and making complex, significant decisions, but no trouble with simple, familiar decisions.

3

Moderately Severe—occasional trouble understanding and making any reasonable decision. For example, unable to choose appropriate clothing for the weather.

Total

Severe—almost always unable to understand and make reasonable decisions.


Social Interaction. This one is a tough one to determine since it depends on the definition of “regularly.” Depending on interpretation, this could easily be given either a 2 or 3 level. Let’s say that “regularly” for this example means frequently, thus assigning a Level 2.

Social Interaction
– Regularly says rude or inappropriate things

0

Interaction is always appropriate.

1

Interaction is occasionally inappropriate.

2

Interaction is frequently inappropriate.

3

Interaction is always or almost always inappropriate.


Orientation. He only has trouble with one of the four: situation—what is the situation that brought him to a particular location. Since only one is a problem, and it happens often (regularly), the Level for this category is 2.

Orientation
– In the morning, he often thinks it is the end of the day

0

Always oriented.

1

Occasionally unable to identify one of the four.

2

Occasionally unable to identify two of the four or regularly unable to identify one of the four.

3

Regularly unable to identify two or more.

Total

Always or almost always unable to identify two or more.

 

Motor Activity. He only forgets how to play the guitar occasionally, so level 1 or 2. Forgetting how to play it entirely would definitely be considered more than mild, so Level 2.

Motor Activity
– Occasionally entirely forgets how to play his guitar (which he’s played since a child)

0

Normal.

1

The ability to perform learned motor activities is occasionally, mildly decreased.

2

The ability is always mildly decreased or occasionally moderately decreased.

3

The ability is always moderately decreased.

Total

The ability is always seriously decreased—completely unable to perform these tasks.

 

Visual Spatial Orientation. The two key phrases here are “almost always” and “unfamiliar”. Both are found in Level 2.

Visual Spatial Orientation
– Almost always gets lost in unfamiliar places—has significant trouble using a map

0

Normal.

1

Mild—occasionally gets lost in unfamiliar areas, has trouble reading maps, following directions, judging distance, etc., but is always able to use GPS devices.

2

Moderate—always or almost always gets lost in unfamiliar areas, can’t read a map, follow directions, or judge distance. Has trouble using GPS devices.

3

Moderately Severe—always or almost always gets lost even in familiar areas. Can’t use GPS devices at all.

Total

Severe—completely unable to find the way from one room to another in a familiar place, unable to touch or name own body parts when asked, etc.


Neurobehavioral Effects. Looking at all three of these symptoms, it seems like he is affected a good majority of the time. He could often lose his job and friendships because of these things too, although it probably isn’t impossible to get a job or maintain a relationship. The most appropriate would be Level 2.

Neurobehavioral Effects
– Losses his temper easily
– Gets into fights regularly over trivial things
– Often grumpy or irritable

0

None of the symptoms interfere with the ability to work or build relationships.

1

Symptoms occasionally interfere with the ability to work or build relationships.

2

Symptoms often interfere with the ability to work or build relationships.

3

Symptoms make it impossible to hold a job or build and maintain steady relationships, or supervision is occasionally required for the safety of self and others.


Communication. Once or twice a month is very occasionally. The only level that would work in this case is Level 1. “Regularly” is just too much.

Communication
– About once or twice a month, he has trouble understanding things he is reading

0

Fully capable of communication by both spoken and written words.

1

Occasional trouble communicating by spoken or written words.

2

Trouble communicating or understanding spoken or written words regularly but less than 50% of the time. Is still mostly able to communicate complex ideas.

3

Trouble communicating or understanding spoken or written words at least 50% of the time. Can communicate basic needs, but may need to use gestures to help communicate.

Total

Complete inability to communicate or understand spoken or written words. Cannot communicate basic needs at all.

 

Consciousness. He is fully conscious, so a Level 0.

Consciousness

0

Fully conscious.

Total

In a vegetative state, coma, or other altered state of consciousness.


Subjective Symptoms. This one is just based on the number of symptoms. There are only two, so Level 0.

Subjective Symptoms
– Headaches once or twice a week which require him to stop his activities and rest
– Has trouble sleeping at least once a week

0

One or two symptoms interfere with daily living, self-care, work duties, or relationships.

1

Mild—three or more symptoms occasionally interfere with daily living, self-care, work duties or relationships.

2

Moderate—three or more symptoms regularly interfere with daily living, self-care, work duties or relationships.


Now that we have all the Level of Impairments assigned to each category, we need to find which is the highest.

Category

Level of Impairment

Executive Functions

3

Judgment

1

Social Interaction

2

Orientation

2

Motor Activity

2

Visual Spatial Orientation

2

Neurobehavioral Effects

2

Communication

1

Consciousness

0

Subjective Symptoms

0

 

The highest Level of Impairment is 3, so this is now converted into the final rating for these TBI residuals.

Level of Impairment Equivalent Ratings

0

0%

1

10%

2

40%

3

70%

Total

100%

 

The final rating for this example would be 70%, coded 8045.

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Common Conditions and Symptoms caused by TBI

Here is a list of some of the most common Stage 2 conditions. These conditions are rated under their own separate codes if they have been officially diagnosed. If they have not been diagnosed, skip it and rate its Stage 3 symptoms.

An infection of the brain caused by TBI, like meningitis, is ratable under its own separate code if it is active. If the infection is not active, then it is just rated on the symptoms it causes. The minimum rating for a diagnosed symptom of an infection of the brain caused by TBI is 10%.
A stroke occurs when the blood flow to the brain is stopped or restricted. Strokes are only rated on the symptoms they cause, and so are not independently ratable. The minimum rating for a diagnosed symptom of a stroke caused by TBI is 10%.
– Leakage or build up of the cerebrospinal fluid (“hydrocephalus”) is not independently ratable. Simply rate any symptoms caused by it separately.
Brain Penetration occurs when an object breaks through the skull and into the brain. Shrapnel, bullets, and other projectiles are common objects that can penetrate the brain. When the object enters the brain, it causes the cerebrospinal fluid to leak out through the hole it created and it kills the brain tissues that are in its path. It is not independently ratable. Just rate the symptoms
Mental Disorders are commonly seen in individuals with residuals of TBI. They should be rated independently if they are officially diagnosed. This includes mood disorders like depression, anxiety disorders like PTSD, dissociative disorders like amnesia, psychotic disorders like schizophrenia that cause hallucinations, and chronic adjustment disorder.
Nerve Damage is often the most common physical result of TBI. The brain controls every function of the body by communicating with the nerves. If a nerve is damaged, the brain is no longer able to control the corresponding area of the body. All diagnosed nerve damage is rated on whichever nerve is affected. Ratings can be found on The Central Nervous System page or the other linked nerve pages.
– Comas or states of altered consciousness can often occur after TBI. States of altered consciousness include any period where the individual is unresponsive to various stimuli. For example, they may technically be awake, but will not respond to someone talking to them, physical touch, pain, etc. Some less severe states of altered consciousness may not require constant hospitalization. If hospitalization is not required, then any symptoms can be separately rated. More severe states, like vegetative state, minimally responsive state, and coma, require hospitalization. A rating of 100% is given while the individual is in the hospital. After they are released, the 100% rating will continue for 3 months, and then the symptoms/conditions directly caused by the state are rated. Ratable symptoms can include bladder infections, pressure sores, and organ failure.
– Disorders of the Endocrine System can occur when the nerves that control the glands which produce hormones are damaged. Diabetes is a common endocrine condition. All endocrine conditions are not rated on the damaged nerves, but on the conditions themselves. Please see The Endocrine System page for conditions and ratings. If a particular endocrine condition is not found on The Endocrine System page, then it is rated under the endocrine condition that best describes the condition and its symptoms. For example, Syndrome of Inappropriate Anti-Diuretic Hormone Secretion (SIADH) is a common condition caused by TBI, and it can be rated either under code 7911, Addison’s disease, or under code 7909, diabetes insipidus, whichever best describes the symptoms.
– Orthostatic hypotension (low blood pressure) can be caused by damaged nerves. It is rated as either atrioventricular block under code 7015 or as peripheral vestibular disorder under code 6204, whichever best matches the symptoms.

If a diagnosed condition is not listed here, search for it on our site. If it has its own ratings, then go ahead and rate the condition under the appropriate code. If not, then rate it under the code that most closely describes the condition and its symptoms.

Below is a list of some of the most common Stage 3 symptoms that can occur following a TBI. Remember that any symptom that is caused by a ratable condition cannot be rated by itself or as part of a second ratable condition. If the Stage 3 symptom is a diagnosed condition and is not caused by another rated condition, it can be rated separately. All other symptoms are rated on the TBI Residuals Rating Table.

Cognitive Symptoms: Cognitive symptoms are ones that interfere with the ability of the brain itself to function properly. Cognitive symptoms include:

Inability to set goals
Inability to solve problems
Inability to understand and make decisions
Difficulty processing and understanding information
Inability to plan
Inability to organize or prioritize activities
Impaired judgment—makes bad decisions because they are unable to understand the consequences of an action
Inability to react to or accept new information
Inability to focus on tasks or pay attention
Inability to try something new when an action is not producing the desired result
Decreased memory
Inability to be spontaneous
Inability to understand or process language (“Aphasia”). This can range from mild, having trouble remembering words or focusing on a conversation, to severe, a complete inability to communicate, read or write. If it is officially diagnosed, it can be rated under code 9305, vascular dementia (not sure why it is rated as vascular dementia instead of dementia due to head trauma, but that’s what the VASRD says).
– Apraxia is the inability to perform familiar tasks when asked because of the inability of the brain to process the information and then give commands to follow through with the task.

Physical Symptoms: Physical symptoms are ones that directly affect the functioning of the body, whether moving muscles or beating the heart. All physical symptoms that are not a part of a ratable condition, are not diagnosed themselves, or are not rated by the VASRD are rated on the TBI Residuals Rating Table as subjective symptoms. If the condition is diagnosed, it is rated as follows:

– Vision problems can be rated on The Eyes page. This includes damage to the oculomotor nerve which can be rated under code 6030.
– Hearing problems, including tinnitus, can be rated on The Ears page.
– Loss of smell and taste can be rated on the Taste and Smell page.
– Damage to the skull bone is rated under code 5296. A skull injury can only be rated if there is a hole in the skull. Any other skull bone injury will heal and so is not ratable.
– Slowed breathing and respiratory failure are rated under code 6834, defects of the chest wall that keep the lungs from inflating.
If it is a direct result of TBI, paralysis or difficulty moving any body part is caused by damage to the nerve that controls it. See The Central Nervous System page to rate the nerves involved.
– Numbness and tingling anywhere in the body is caused by nerve damage. See The Central Nervous System page and the other linked nerve pages to rate the nerves involved.
The inability to speak or the impaired ability to speak (dysarthria, aphonia) because of physical causes, like the necessary muscles are unable to move, is caused by damage to one or more of the cranial nerves (although only one nerve can be rated for this symptom). See The Cranial Nerves page to rate whichever nerve is most affected.
The inability to swallow is rated as impairment of the glossopharyngeal nerve or the hypoglossal nerve, whichever is damaged the most.
– Difficulty chewing is rated as impairment of the trigeminal nerve.
– Paralysis of the facial muscles is rated as impairment of the facial nerve.
– Seizures: In 25-50% (depending on the severity) of cases, individuals affected by TBI experience seizures within days of the initial trauma. In the majority of these cases, the seizures stop within a week. If they continue beyond a week, then a seizure disorder can be diagnosed and rated. Similarly, seizures may not begin immediately, but may begin months or years after the initial injury. In these cases, there must be proof that the seizures are directly related to the TBI. All seizure conditions are rated in the Epilepsy and Seizures section of The Central Nervous System page.
– Twitching or tremors of the muscles can either be rated as Athetosis under code 8107 or as Sydenham’s Chorea under code 8105, whichever is diagnosed.
– Migraine headaches are rated under code 8100.
– Pain is often a result of TBI. Since the nerves sense pain, any nerve damage will most likely also have pain in whatever area that nerve affects. Not all pain caused by TBI is a result of nerve damage, though. Pain itself is not a ratable symptom, but if it is caused by a ratable condition, then the minimum rating that condition can have is 10%.
– Urinary Incontinence can occur when the nerves to the muscles that control urination are damaged. This is rated as voiding dysfunction caused by a neurogenic bladder under code 7542, not under the damaged nerve.
– Bowel Incontinence occurs when the nerves that control bowel movements are damaged. This is rated as a neurogenic bowel under code 7332, not under the damaged nerve.
– Problems staying balanced are rated under Balance Disorders.
– Nausea and vomiting are not rated by the VASRD.
– Muscle cramps are not rated by the VASRD.
– Dizziness is not rated by the VASRD.
– Insomnia or other trouble sleeping is not rated by the VASRD.
– Loss of coordination could include bumping into things, dropping things, inability to play sports, difficulty driving safely, trouble working with machinery, etc. It is not rated by the VASRD.
– Increased sensitivity to light or sound is not rated by the VASRD.
– Increased fatigability is how fast the body becomes tired during physical activities. It is not rated by the VASRD.

Emotional and Behavioral Symptoms: Emotional and behavioral symptoms affect psychological health. If a mental disorder has not been diagnosed, then each symptom is rated on the TBI Residuals Rating Table as a neurobehavioral effect. Common symptoms include:

Moodiness
Unpredictability
Agitation
Irritability
Impulsiveness
Verbal aggression
Physical aggression
Anger
Belligerence
Apathy
Nightmares
Inappropriate behavior
Poor motivation
Lack of cooperation
Fear
Avoidance of places, people, and things
Amnesia
Startling easily

These are not the only symptoms that could be caused by TBI. If a diagnosed symptom is not listed here, simply search for it on our website. Not all symptoms are given a code and rating in the VASRD, so as long as it is diagnosed, it can be rated under the code that most closely defines it.

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Examples of Rating TBI

Okay, let’s work a few examples to see how to put these principles in action.

Example 1. A service member received a traumatic brain injury (TBI) from an IED blast. Six months after the incident, he was being separated from the service because of his residual TBI symptoms. At the exam, he reported the following symptoms: avoidance, anxiety, nightmares, depression, decreased memory, intrusive thoughts, pain and tingling in his wrist, limited motion in the wrist, the inability to speak, and trouble swallowing. Each of these symptoms was judged to be a direct result of the TBI, not another condition.

The following conditions caused by TBI were officially diagnosed: anxiety disorder, damage of the vagus nerve, damage of the hypoglossal nerve, and damage of the ulnar nerve.

Step 1: Let’s first put these conditions and symptoms into a table.

Stage 1

Traumatic Brain Injury

Stage 2

Anxiety

Vagus Nerve

Hypoglossal Nerve

Ulnar Nerve

Memory Loss

Stage 3

Avoidance

Nightmares

Intrusive Thoughts

Depression

Can’t Speak

Trouble Swallowing

Can’t Speak

Trouble Swallowing

Wrist Pain

Limited Motion of the Wrist


It’s important to find out from the physicians’ reports which symptoms belong to which diagnosed condition so that each can be appropriately rated.

Step 2: Once all the conditions and symptoms are sorted, go ahead and rate all of the diagnosed Stage 2 conditions. In this case, those would be the anxiety disorder, damaged vagus nerve, damaged hypoglossal nerve, and damaged ulnar nerve.

Anxiety disorder is a mental disorder, so find it on the Mental Disorders page. (If you don’t know where to look for it, search for it on this website.) You’ll notice on this page that there are 6 codes for the different kinds of anxiety disorders. The physician should clearly define which type of anxiety disorder it is. If the physician does not specify the type of anxiety or if the type of anxiety specified is not listed, it is rated under code 9410, for all other types of anxiety disorders. Since the type of anxiety disorder in this case is not specified, this is the code we’ll use.

If you read all the information on anxiety disorders, you’ll find that they are rated under the Psychological Rating System. If you click on the link to that rating system, detailed instructions are given on how to rate the anxiety disorder. We’re not going to delve into this in this example simply to keep things clear and simple. All the guidance is there, however. Let’s say that we followed the Psychological Rating System and determined that the Anxiety Disorder warrants a 10% rating. The final code for the anxiety disorder would be 8045-9410. The first tells us that the anxiety disorder is caused by TBI. Remember, all conditions rated separately have the TBI code placed in front of it like this.

Next condition: Pay close attention on this one. If you look at the chart we made, you’ll notice that both the damaged vagus nerve and the damaged hypoglossal nerve have the exact same symptoms. A single symptom can only be rated once, even though both nerves have been diagnosed as clearly damaged. Often more than one nerve helps control certain functions, so this can happen regularly. Since they share the same symptoms, only one can be rated—the one that is damaged the worst, if both are damaged equally, then rate the one that will provide the higher rating. Let’s say for this example that the hypoglossal nerve is damaged the worst.

Let’s head over to The Cranial Nerves page to rate the hypoglossal nerve. Again, we won’t get into the exact rating process for the hypoglossal nerve since it is clearly explained on The Cranial Nerve page. Let’s say that it is rated 30% under code 8212. The final code will be 8045-8212.

Only one diagnosed condition left: damaged ulnar nerve. This condition can be found on the Nerves of the Low Back and Legs page. Remember to read everything under the ulnar nerve and its rating system. For this example, we’ll assign this condition a rating of 10% under code 8045-8616.

So to sum-up the ratings for our diagnosed conditions, we have three ratings as follows:

Condition

Code

Rating

Anxiety Disorder

8045-9410

10%

Damaged Hypoglossal Nerve

8045-8212

30%

Damaged Ulnar Nerve

8045-8616

10%

 

Step 3: We have the first part done. Now all we have left to do is rate any leftover conditions/symptoms that were not covered by the diagnosed conditions. In this case, there is only one—memory loss. This condition has not been diagnosed, so let’s find where it would fit in the TBI Residuals Rating Table.

Here is an excerpt of the Executive Functions section where memory problems are categorized.

Executive Functions (memory, attention, concentration, goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, spontaneity, and flexibility)

0

No problems.

1

Very Mild—trouble with one or more of the executive functions causes occasional minor problems like trouble remembering names, following conversations, misplacing items, etc., but overall functioning is fine. There is no evidence of these problems when tested.

2

Mild—trouble with one or more executive functions causes occasional minor problems, but overall functioning is fine. There IS evidence of these problems when tested.

3

Moderate—trouble with one or more executive functions causes fairly regular problems that interfere with the ability to work and care for self.

Total

Severe—trouble with one or more executive functions causes the complete inability to work and care for self.

 

Just like with the diagnosed conditions, we’re not going to get into specifics of how to rate the memory loss based on these requirements. Re-read the TBI Residuals Rating Table section for step-by-step guidance on using the table. For this example, we’re going to say that the memory loss warrants a Level of Impairment of 1.

Since it is the only condition, the highest level of impairment is 1, so this is now translated into its equivalent rating based on this table:

Level of Impairment Equivalent Ratings

0

0%

1

10%

2

40%

3

70%

Total

100%

The rating for this last symptom is 10%. This is simply listed on the Rating Authorities’ Rating Decision as Residuals of TBI, code 8045.

Step 4: We’re done! We now have all the ratings that are allowed for all the conditions and symptoms caused by TBI in this case. Here they are summed up:

Condition

Code

Rating

Anxiety Disorder

8045-9410

10%

Damaged Hypoglossal Nerve

8045-8212

30%

Damaged Ulnar Nerve

8045-8616

10%

All other TBI residuals

8045

10%

 

Let’s do another example to make sure we’ve got it down.

Example 2. A service member received a traumatic brain injury (TBI) from falling down a flight of concrete stairs. Eight months after the incident, he was being separated from service because of his lasting TBI symptoms. At the exam, he reported the following symptoms: fatigue, trouble walking, seizures, memory loss, weakness and pain in the right leg, and trouble concentrating. Each of these symptoms was judged to be a direct result of the TBI, not another condition or separate injury (remember that if they are not directly caused by TBI, they cannot be rated here).

The following conditions caused by TBI were officially diagnosed: chronic fatigue disorder, meningeal adhesions, petit mal epilepsy, and damage to the obturator nerve (this nerve travels down the legs).

Step 1: Let’s first put these conditions and symptoms into a table.

Stage 1

Traumatic Brain Injury

Stage 2

Chronic Fatigue Disorder

Meningeal Adhesions

Obturator Nerve Damage

Stage 3

Fatigue

Trouble Concentrating

Trouble Walking

Epilepsy (seizures)

Memory Loss

Trouble Walking

Weakness

Pain

 

It’s important to find out from the physicians’ reports which symptoms belong to which diagnosed condition so that each can be appropriately rated. In this case, notice that although epilepsy was officially diagnosed, we’re going to say that it was officially judged to be caused by the meningeal adhesions, and so it is listed in Stage 3 instead of Stage 2.

Step 2: Once all the conditions and symptoms are sorted, go ahead and rate all of the diagnosed Stage 2 conditions. In this case, those would be the chronic fatigue disorder, meningeal adhesions, and damaged obturator nerve. The epilepsy is not ratable separately since it is caused by the meningeal adhesions.

We hit a problem with the symptoms when trying to rate chronic fatigue disorder and obturator nerve damage. Notice that both have the same symptom: trouble walking. A single symptom cannot be rated twice, so we must determine whether or not the chronic fatigue disorder or the obturator nerve damage has enough other symptoms to make them unfit for duty and thus still ratable without the trouble walking symptom. It could easily be said that the obturator nerve damage has serious enough other symptoms to be rated without the walking symptom. Weakness and pain in the leg will definitely limit the ability of the service member to perform in a deployed environment. So, that we can rate separately.

Depending on the severity of the chronic fatigue disorder, it could easily be said that fatigue and trouble concentrating (again depending on their severity) are not enough to make the service member unfit. Since the damaged nerve condition is not using the walking symptom, however, the fatigue disorder can use it and so is still ratable. Make sense?

Chronic fatigue disorder is considered an immune disorder and so can be found on the Infectious Diseases and Immune Disorders page. (Remember, if you don’t know where to look for it, search for it on this website.) Again, we’re not going to delve into exactly how to rate this since all the information is on that page. For this example, we’ll just say that it is rated 20%. The final code for the chronic fatigue disorder would be 8045-6354. Always put the TBI code first.

Meningeal adhesions are not directly rated by the VASRD, so they do not have their own code. Since it was officially diagnosed, however, it is ratable. The basic rule is that whenever a condition does not have its own code, rate it under the code that is closest. We have a list of the most common conditions that are not coded by the VASRD on our Analogous and Equivalent Codes page. If we go to this page, we’ll find that meningeal adhesions are rated under code 8019, cerebrospinal meningitis. Use this code to rate the condition—we’ll say it rates 20%. The final code would be 8045-8019 (since this condition is caused by TBI, ignore the directions on the Analogous Ratings page about the first 4-digit code and simply use the TBI code).

Obturator nerve damage. This condition can also be found on the Nerves of the Low Back and Legs page. Remember to read everything under the obturator nerve and its rating system. For this example, we’ll assign this condition a rating of 10% under code 8045-8628.

To sum-up the ratings for our diagnosed conditions, we have three ratings as follows:

Condition

Code

Rating

Chronic Fatigue Disorder

8045-6354

20%

Meningeal Adhesions

8045-8019

20%

Damaged Obturator Nerve

8045-8628

10%

Step 3: If there were any leftover symptoms or conditions that were not covered in these diagnosed conditions, then we would continue to rate them using the TBI Residuals Rating Table, but since all the symptoms were already covered, we’re done. We have all the ratings that are allowed for all the conditions and symptoms caused by TBI in this case. So these are the final codes:

Condition

Code

Rating

Chronic Fatigue Disorder

8045-6354

20%

Meningeal Adhesions

8045-8019

20%

Damaged Obturator Nerve

8045-8628

10%

Not too bad, right? Just remember to follow the steps and go back and re-read things if any questions arise. Rating TBI is not too bad as long as you stay organized.

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Principles that Apply

Pyramiding: A single condition can only be rated once! However, if another condition exists that is additional to the endocrine condition (not simply caused by it), then it can also be rated.

Probative Value: If two exams record the condition differently, the exam with the most thorough data and performed by the most qualified person in that specialty will be the exam the rating is based on.

A Tie Goes to the Veteran: If there are two equally strong exams with conflicting information, or if the condition can be equally rated under two different codes, then the one that gives the highest rating will be assigned. Every conflict should be resolved in favor of the higher rating.

Accurate Measurements: It is essential that the necessary information to rate your condition is recorded by the physician in your exam. With the information on this page, you should know what needs to be measured and recorded. Make sure this happens correctly to ensure that you receive a proper rating.

Hospital or Convalescent Ratings: Some conditions require periods of hospitalization or constant medical care (at-home nurse, etc.). Any condition that requires this is rated 100% during this intensive treatment. Once it ends, then the 100% rating will continue for a certain period. This period is 3 months unless another length (6 months, 1 year, etc.) is directly specified in the condition ratings. Some patients may need more time to recover than others, so the physician or Rating Authorities can lengthen this time period if they see fit.

Please see the VASRD Principles page for further guidance.

For related conditions, please see the Mental Disorders, The Central Nervous System, The Cranial Nerves, Nerves of the Upper Back and Arms, Nerves of the Low Back and Legs, The Skin, Scars, The Eyes, The Ears, Taste and Smell, The Mouth and Teeth, Facial Muscles, and The Skull pages.

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