The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.”Įvaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face visual impairment hearing loss and tinnitus loss of sense of smell and taste seizures gait, coordination, and balance problems speech and other communication difficulties, including aphasia and related disorders, and dysarthria neurogenic bladder neurogenic bowel cranial nerve dysfunctions autonomic nerve dysfunctions and endocrine dysfunctions. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” tableĮvaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings - mental disorders) when there is a diagnosis of a mental disorder. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” In a given individual, symptoms may fluctuate in severity from day to day. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Each of these areas of dysfunction may require evaluation.Ĭognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses.Ĩ045 Residuals of traumatic brain injury (TBI): Determinations as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded subjective residuals will be accepted when consistent with the disease and not more likely attributable to other disease or no disease. Note: It is required for the minimum ratings for residuals under diagnostic codes 8000-8025, that there be ascertainable residuals. At this point, if the residuals have stabilized, the rating will be made on neurological residuals according to symptomatology. Note: The rating in code 8021 will be continued for 2 years following cessation of surgical, chemotherapeutic or other treatment modality. Note: Consider the need for special monthly compensation.Ĩ019 Meningitis, cerebrospinal, epidemic: Note: Rate upon the severity of convulsions, paralysis, visual impairment or psychotic involvement, etc. Rate the vascular conditions under Codes 8007 through 8009, for 6 months Note: The rating in code 8002 will be continued for 2 years following cessation of surgical, chemotherapeutic or other treatment modality.
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