- April 2024 -

DIAGNOSIS ELEMENTS

The diagnosis and supporting details are crucial for proper rating of an examinee's claim because it directly determines the validity and extent of the claim by establishing a clear connection between the examinee's service and their current health condition.

• Date of diagnosis: This can be used to determine the effective date if service connection can be established or for any other rating considerations.
• Symptoms: Provides current clinical presentation and level of severity of the claimed condition.
• Medical history: Based on an interview and/or records review, provides crucial information about course of condition, relevant family and social history, past treatment, etc.
• Service records: Provides crucial information on previous workup of claimed condition to aid in determining if it was diagnosed and if it was treated during service.
• Physical examination: Clinical observations can provide significant information supporting or excluding a diagnosis.
• Diagnostics: Provides clinical evidence to support, establish, or confirm a diagnosis (or to exclude a diagnosis) to provide the current status of established conditions.

SPIROMETRY GUIDANCE

The following are the only acceptable medical contraindications for not conducting PFT:

• When the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less.
• When pulmonary hypertension (documented by an echocardiogram or cardiac catheterization), cor pulmonale, or right ventricular hypertrophy has been diagnosed.
• When there have been one or more episodes of acute respiratory failure.
• When outpatient oxygen therapy is required.

For VA Rating purposes, age alone is NOT an acceptable factor for PFT deferral. Because of spirometry equipment limitations for examinees 79 and older, a manual calculation must be done to determine the predicted values.    

REMINDER 1: Post-Bronchodilator Requirements - Must be performed if pre-bronchodilator results are 80% or worse.

REMINDER 2: Recording BEST FEV1/FVC, not % predicted - Correct: The FEV-1/FVC is obtained by taking the best actual measured value of FEV-1 divided by the actual measured value of FVC. These values are typically listed under Pre- Test or Post-Test BEST column. Incorrect: FVC % predicted and the FEV-1 % predicted are taken directly from the % Pred column on the PFT diagnostic. However the FEV-1/FVC is not taken from the % Pred column. For VA rating purposes, it is incorrect to provide the FEV-1/FVC from the % Pred column.

NOTE: Since all PFT result templates vary, it is critical to review carefully and ensure the proper values are used for reporting. Example: Convert decimal into percentage when applicable. Enter 77 instead of 0.77.

The following in-form example will appear as a reminder on which value to report for FEV-1/FVC:

ISCHEMIC HEART DISEASE

Section II Medical History Question 2B asks which of the heart condition/s diagnosed under Section I Diagnosis, qualify/ies under the generally accepted medical definition of Ischemic Heart Disease (IHD).

IHD is defined as:

• acute, subacute, and old myocardial infarction (MI)
• atherosclerotic cardiovascular disease (ASCVD) including coronary artery disease, including coronary spasm) and coronary bypass surgery
• stable, unstable, and Prinzmetal's angina
• ischemic cardiomyopathy

Once a condition/s is/are identified, it is important to enumerate EACH condition that were diagnosed.

Then ensure to address the etiology for EACH listed diagnosis.

For example, diagnosis rendered in Section I was coronary artery disease (CAD) then in Section II, re-state the diagnosis that qualify under IHD.

2C Heart Conditions #1 (provide etiology) would be “hyperlipidemia.”

PROVIDER SPOTLIGHT

Leidos QTC Health Services would like to take a moment to congratulate Dr. Frances Ong on a significant accomplishment.

Dr. Ong was recently honored with a prestigious award for professionalism, integrity, respect, excellence, collaboration, and compassion through Baptist Health Medical Group. This accolade is only awarded to one person each year from a pool of over 200 physicians. This is a phenomenal achievement and we are proud that Dr. Ong has chosen to partner with QTC to serve our Nation's veterans!