J Basser: 0:05

It's time for the Exposed Vet Radio Show. The Exposed Vet Radio Show, we discuss issues affecting today's veteran. Now here's your host, john and Ray. Welcome, ladies and gentlemen, to another episode of the Exposed Vet Radio Show. On this beautiful sunshiny, october 3rd 2024. Years going by, this is the month of Halloween, so be careful with the gooks and goblins out there, because they're going to get more prevalent as the month goes on. Today we've got Mr Ray Cobb. He's riding side saddle over on the side car in the Harley we're riding. How are you doing, ray?

Ray Cobb: 0:44

I'm doing great Beautiful day down here today. That great fall weather start to set in cool in the morning. We got plenty of rain this last month, so we're liable to have a gorgeous fall down this way.

J Basser: 0:58

Well, I'm glad I like seeing these things get real pretty.

J Basser: 1:02

Got a treat for you.

J Basser: 1:03

Today, folks, we've got our resident instructor. I guess her name is Bethany Spangenberg. She is valid for vet, she's the owner of the company and we've been discussing some stuff here over the last year or so about DBQs and different disabilities, and today y'all need to listen up real close because we're going to talk about the ears. How you doing, bethany?

Bethanie Spangenberg: 1:28

I'm doing well enjoying this beautiful sunset that we get a little bit earlier, and glad to be on this side of was it Hurricane Helene or Helen, what they're saying Because we had some flooding here in Southern Ohio and so I'm glad to be on this side of the storm Good.

J Basser: 1:50

Well, it was a rough time. It still is a rough time. My place is wiped out, especially North Carolina and eastern Tennessee. It's bad. They say I-40 is going to be closed until September of 2025 between Asheville and Knoxville.

Bethanie Spangenberg: 2:07

Wow, yeah, I saw some videos coming out of there. It's terrible.

J Basser: 2:13

Yeah, it is, but I hear today they have no money to do anything. I remember feeling they didn't have any money. They gave it all away, so I hope that's not the case. If it is God, what a mess.

Ray Cobb: 2:32

There's one little community up there in East Tennessee up close to Elizabethan. They've lost three fire trucks, four police cars and two ambulances in the flood. And I know our county. We gave them two police cars, two patrol cars.

J Basser: 2:57

Okay.

Ray Cobb: 2:59

To try to help, you know, so that they can at least get around and do some stuff.

J Basser: 3:04

Is the department trying to get it, so they can at least get around and do some stuff.

Ray Cobb: 3:07

Is that part of the Tri-City? Well, it would be in the Tri-City section yes, kingsport, johnson City area. Yep, yep.

J Basser: 3:15

I'm just trying to.

Ray Cobb: 3:16

Elizabeth is about. Oh, I guess it's only about 20 or 25 miles northeast of Johnson City. Okay.

J Basser: 3:25

That's close of Johnson City, okay, that's close to eastern Kentucky. Okay, well, guys, fair for them. You send whatever you can. You know I mean Costco here is already out of water. It's been at all down there. So you know everything is getting balled up. But I also got the porch crack going on folks, so you think things can get bad. We're fixing that empty shelves again and things are going to skyrocket. So I hope people grow a garden this year because they're going to need the vegetables.

Bethanie Spangenberg: 3:54

Hopefully we get the rain to support the garden too.

J Basser: 3:57

We need the rain. We also need to get somebody in the gubber to put a stop to that strike and put it back to work. That's what needs to happen, All right. Well, let's talk about the ears, Bethany, because we all need to be able to understand the situation with the ears. We've got a couple of bets missing in. I know one gentleman. He hasn't filed a claim yet, but I think he's fixing to. I think he wants to hear about the ears Well.

Bethanie Spangenberg: 4:24

I appreciate them attending and hopefully they learned something from what we talked about today. If you are a new listener, we've been covering these DBQs one by one each month.

Bethanie Spangenberg: 4:35

I don't think from my standpoint these DBQs are talked about enough because we want to cover. Our goal in covering these is kind of talking about each section and what the veterans should expect and have prepared for their condition, talk a little bit about what each rating decision means and just kind of have a better understanding of how this process works from the medical expert side of things. So not necessarily the most hot topics or the most controversial stuff, so hopefully we can keep you a little bit entertained. So I'm going to jump into the Ear Conditions DBQ. This DBQ is nine pages long and it has to do with the inner ear, the middle ear, the outer ear and infections. This is not specific to hearing loss and tinnitus or ringing in the ears. Those are separate. But before we dive into each section I do want to talk a little bit about anatomy and what some of these terms mean.

Bethanie Spangenberg: 5:46

So when we?

Bethanie Spangenberg: 5:46

talk about the ear and the ear structures, we reference them as the external ear, the middle ear and the internal ear. So the external ear is the part that you can touch. We call that the pinna, and also includes the ear canal. That is considered the external ear. Now, your eardrum, or what we call the tympanic membrane, the outer portion, is part of the external ear and it creates a seal from everything else on the inside. So there is not supposed to be any air or fluid coming from the inside of the ear to the external portion, so that that eardrum plays a large portion of our hearing and protecting our brain from any type of infection. And protecting our brain from any type of infection. Now, the middle ear is the pressure system. It has to do with the eustachian tube, which is connecting the inner ear to our sinuses. So when we change pressures or change elevation, that eustachian tube adjusts the pressure in the middle ear so that way we're not having ear pain. So, for example, if you've ever been on an airplane, you'll feel your ears pop. What you're actually feeling is that eustachian tube adjusting to the pressure and the elevation change. So that's necessary in order to protect the mechanisms for our hearing.

Bethanie Spangenberg: 7:29

Now, the internal ear is your balance center and it also helps you to understand your position. Now, when I explain how the inner ear kind of functions, or the internal ear functions, I'm going to use a layman example, a very simplistic example. So if you're a medical professional listening to me discuss this, just know that I'm not using technical terms. So when you think of how the inner ear functions for balance and position change, I want you to think about a snow globe and the confetti or the glitter inside the snow globe. So our internal ear functions using a fluid and crystals within the fluid. So if you take a snow globe and you're not shaking it up right now, but you're holding the snow globe and you turn the snow globe, which shifts the glitter to the bottom because of gravity. That is the same process that occurs when we change our position. So those crystals within our ear adjust to the gravity and move to give signals about where our head is positioned in space.

Bethanie Spangenberg: 8:54

So if you shake up that snow globe, that is chaos in your inner ear and that's where we can start to get symptoms of dizziness in your inner ear and that's where we can start to get symptoms of dizziness and we can intentionally like as children when we're on the merry-go-round, we can intentionally trigger the dizziness symptoms by spinning really fast right Makes us dizzy. But as we get older we could be more sensitive to that change and it can create a disease. And that's where we start to get some of our diseases known or symptoms such as vertigo, the dizziness that we're not trying to trigger or we get. The most common one people talk about is the benign positional peripheral vertigo, or BPPV. That's a big one that people like to claim or even some symptoms of Meniere's disease, and so we'll break down each condition as we go through the DBQ. But I really just wanted to put that out there and that way everybody understands the function of each section of the ear. Does that make sense? The function?

J Basser: 10:09

of each section of the ear. Does that make sense?

Bethanie Spangenberg: 10:20

Yes, it does. Okay, All right. So as we go on to page one, the sections here on page one are the standard questions that we see in every DBQ. It talks about disclosing the relationship between the examiner and the veteran, it talks about what evidence was reviewed and then it asks about the diagnosis that is to be addressed. As always, I highlight the first box in the diagnosis section, and the first box that the medical examiner can mark reads the veteran does not have a current diagnosis associated with any claimed conditions listed above. And this is where I emphasize that a diagnosis is important to the clinician in order to understand the relationship for your disability claim. So, while it may not be legally required, it's a legal argument If you don't have a diagnosis. I will say that from the medical expert side of things. If you have a diagnosis before you go into that compensation and pension exam, you're saving yourself so much time and so much energy when it comes to your disability claim.

Bethanie Spangenberg: 11:25

It is absolutely recommended from the medical expert standpoint to go into your comp and pen with a diagnosis. So some of the diagnoses that are listed on this DBQ are on the top of page two. Some of these medical terms may ring a bell to you. So as I go through there, just know that these are the conditions that we're also going to be discussing briefly today. So Meniere's syndrome, peripheral vestibular disorder this is where the vertigo falls under. We have the benign paroxysmal positional vertigo or the BPPV that I mentioned. We have chronic otitis externa, and that is the external ear infection. We have chronic superative otitis media, so media is middle, and so that is a chronic infectious disease inside the middle ear. We have a chronic non-superlative otitis media, so it's more of a, rather than it being an infectious fluid. It's a different type of like oil almost that's in the middle ear. Then we have mastoiditis, which is an infection of the bone, and then we have otosclerosis, which is actually arthritis of the bones inside the ear Part of hearing. There is vibration that occurs between these itty bitty tiny bones of the ear, vibration that occurs between these itty-bitty tiny bones of the ear and you can actually develop arthritis in those itty-bitty bones from vibration or loud noises and it's interesting that even those teeny bones can develop arthritis. But that's what the otosclerosis is okay. But that's what the otosclerosis is okay.

Bethanie Spangenberg: 13:28

One other condition that's not listed on this but is discussed in the rating schedule is tympanic membrane or that eardrum perforation, and I just wanted to throw that in there because it does not have a rating, a disability rating, meaning that it's listed with the diagnostic code but it's at a 0%. It's not compensable. The reason why I bring that up is because the eardrum perforation can actually be common for veterans, whether it comes from an ear infection or sinus issues. Even trauma can cause an eardrum rupture or perforation and I just want to mention that it is not compensable. But you can get it service-connected and then file conditions that may have developed secondary to that eardrum perforation.

Bethanie Spangenberg: 14:15

So I think that's important to briefly mention on there as we move into Section 2 of the second page. This is the medical history. We've talked about this with every DBQ. That is where the examiner can review your statement or they can ask you interview questions to plug that information inside the medical history. Page three, the top of page three, talks about medications that you may be taking for your ear condition, and then section three is where we really start diving into what rating percentages apply to these ear conditions. Do you guys have any questions so far about what we've talked about or what I've brought up for the DBQ?

J Basser: 15:10

That was just thinking. Yep, three phases, you've got the outer ear, the middle ear and the inner ear. Is that the face of what you're saying?

Ray Cobb: 15:21

Yes, that's what I'm saying.

J Basser: 15:22

Okay, so which one is the station, tube dysfunction being the middle ear?

Bethanie Spangenberg: 15:28

That's going to be the middle ear.

J Basser: 15:29

Okay, that's what I was like. Okay, it's time to wrap my burner in this, because I've been fighting this stuff for years.

Ray Cobb: 15:37

Okay, question real quick, bethany when they say you have an ear infection, is that most of the time on the outer ear?

Bethanie Spangenberg: 15:50

No, so when somebody says that's going to be the middle ear. So what normally happens is the most common term, like when you hear young children have a double ear infection. Most commonly what that is is they've looked inside the ear canal and they can see fluid and irritation of that eardrum. Now, because that eardrum creates a separation between the outside world and the inside sinus cavity, the fluid is actually and the infection is actually inside of that metal ear. The interesting part is that the eustachian tube, which controls the pressure and is supposed to allow air in and out of that middle ear, what can happen is bacteria from the sinuses can go up into that eustachian tube and irritate what's inside the middle ear. So most often when we have these middle ear infections or young children have ear infections, it's not necessarily that the ear is not functioning correctly. It's that eustachian tube that's not functioning correctly and that's coming from sinus irritation. So sinusitis, allergies, cold viruses.

Bethanie Spangenberg: 17:18

So sinusitis, allergies, cold viruses those things are what contributes to dysfunction of that eustachian tube and then prompts bacteria into the middle ear and causes those ear infections.

J Basser: 17:29

So that's a good question because now we're connecting dots of rhinitis, sinusitis, ear infection, that kind of thing. So that's a good question, but that usually requires tubes to be placed in right. It usually requires what Tubes, tubes?

Bethanie Spangenberg: 17:49

Ear tubes, yeah, tubes, yeah. So ear tubes can be controversial, especially in your younger children, because sometimes they're really. Some clinicians believe that they're not treating the underlying issue. They're not treating the allergies or the sinus issues, or whether it's environmental allergies or symptomatic treatment of viruses, so they're not getting control of that inflammation within the sinus cavity which is causing that tube to malfunction.

Bethanie Spangenberg: 18:15

So, some clinicians believe that ear tubes are a band-aid on the problem and they're not truly addressing the issue, and ear tubes can then go on and cause scarring, which causes hearing loss and issues within you know as they age. Some clinicians believe that they should be treating the underlying issue rather than jumping to ear tubes.

Bethanie Spangenberg: 18:39

I don't know that's a topic. That's a whole other show, I think in and of itself. But as adults, I have seen adults get ear tubes because they can't get control of the sinus issue and it leads to frequent ear infection. Ear tubes as adults are difficult because you don't have the healing and recovery that you have in your childhood.

Bethanie Spangenberg: 19:04

So ear tubes as adults you're really taking a risk of hearing loss because you don't have the healing and recovery that you have in your childhood. So ear tubes as adults you're really taking a risk of hearing loss that may develop following the ear tube placement. That's a discussion between each clinician and each patient with their provider.

J Basser: 19:20

How about 17 over 20 years?

Bethanie Spangenberg: 19:24

That can cause some hearing loss.

J Basser: 19:26

What did you say?

Bethanie Spangenberg: 19:28

Exactly so. While we're on the topic of the ear infection, like when somebody goes in and says an ear infection, the only way that you're really going to get an external ear infection is from something irritating the skin surface, Because the eardrum does create a barrier between the outside world and the inside of the sinus cavity. Then anything that is on the outside of the eardrum that gets infected is either coming from trauma of the skin, like people putting paper clips in their ear to get something out of their ear, or somebody taking their fingernail and scratching their ear by accident, like something itched and then they scratched their ear. So whenever we talk about infections of the external ear, it's most commonly going to be coming from some type of trauma to the skin surface itself.

Bethanie Spangenberg: 20:30

Okay.

Bethanie Spangenberg: 20:33

So when we jump to page three, section three, this is where a lot of the ratings are Like. This is the dense area of where our rating percentages come from for vestibular conditions, and when we talk about vestibular conditions, we're talking about conditions of the internal ear that affects our balance and our position. So when I talk about, or I mentioned the peripheral vestibular disorder, okay, the peripheral vestibular disorder, okay, that's what they are referencing in Diagnostic Code 6204, but that's also commonly vertigo okay.

Bethanie Spangenberg: 21:18

This is also the benign, paroxysmal positional vertigo which we get. A lot of veterans that have that diagnosis and they claim that secondary to a condition that also falls under diagnostic code 6204. Now, clinically, meniere's syndrome is also a peripheral vestibular disorder that affects the internal ear, but it gets its own rating schedule and its own diagnostic code under 6205. And so as I go through Section 3, I'm going to kind of talk about what each percentage means for these conditions. Okay, so Section 3 asks specifically about hearing impairment with vertigo and they're asking that because of Meniere's disease. Now I guess I should explain that Meniere's disease does affect the internal ear but it also creates symptoms of hearing loss and ringing of the ears and Meniere's disease when a veteran gets diagnosed with it it's something that they have been dealing with for a while. That usually takes several doctor's visits in order to capture that diagnosis.

Bethanie Spangenberg: 22:42

Often we see patients will come in and they will talk about having some hearing issues and primarily the vertigo complaints, the dizzy that you know. They feel like the room is spinning and they may develop some nausea with that dizziness, and so when they come in, the primary care doctor or the mid-level practitioner may try to do a physical examination, they may try to do some what we call maneuvers in order to narrow down what may be occurring, be occurring. So there's some clinical tools we can use as far as like position change to trigger the symptoms, or head movements to trigger the symptoms, and if those become positive, then we can say, okay, well, we are suspecting that it may be this condition, and then we give a medication or we throw a medication out and we say okay we're going to try this medication.

Bethanie Spangenberg: 23:43

If it helps, great. We'll have you follow up in a couple of months to see if anything changes. So if the veteran or the patient says, well, it went away with that medication, sometimes they don't come back, and then a few months down the line they may develop another episode, and so it can typically take a while before a veteran or a patient narrows down the diagnosis of Meniere's disease. What happens is those episodes become more frequent, or they're not helped with medication, or they're persistent, and so it can take a while for a veteran to actually capture the diagnosis of Meniere's. They are often referred to a specialist, either an ears, nose and throat specialist or a team of an ENT specialist and an audiologist, before they truly get the workup that is necessary to diagnose them with Meniere's disease.

Bethanie Spangenberg: 24:43

With Meniere's, if you have hearing impairment and a vertigo less than once a month, you get a 30% rating. The next symptom for Meniere's rating is hearing impairment, with attacks of vertigo and difficulties with gait or unsteadiness. If you get that one to four times per month, it's a 60% rating for Meniere's. If you get it more than once weekly, it is a 100% rating for Meniere's. At Valor for Vet. That is a big one that veterans are trying to service connect once they capture the diagnosis of Meniere's because of that high rating and it can be persistent and overwhelming and cause the nausea and vomiting and discomfort with the disease because of the symptoms. So, continuing with Section 3 of the symptoms, tinnitus is mentioned on there. That's really just to prompt the additional DBQ. Hearing loss is also on the symptom questionnaire and that's again to prompt the other DBQ for the audiologist to conduct for hearing loss and tinnitus.

Bethanie Spangenberg: 26:03

And then the other question on the symptom section for section three is vertigo, which we've talked about significantly, and if you have vertigo it is a 10% rating. Or you have vertigo with the staggering symptoms or the gait unsteadiness, the staggering symptoms or the gait unsteadiness, those together are a 30% rating for vertigo or the vestibular inner ear disorders. So if you have a vestibular or inner ear condition, often the symptoms are the dizziness and some unsteadiness on your feet because of the dizziness. So that's a 30% rating for those conditions. So there could be a little bit of meat on the bones, I guess, for those conditions if you get them service connected. Any questions about the inner ear?

J Basser: 27:09

As far as unsteadiness, I mean, if you've got that condition, you're in steady walking, you're going to need help transferring and things like that where a person falls off or a dependent is based on something like that. They can.

Bethanie Spangenberg: 27:21

They can, depending on the frequency of the symptoms. If it's something that occurs once or twice a year, maybe not, but if it's something that is persistent and you require the assistance of another because of it, then absolutely. Now, if we move on to Section 4, this is to do with the ear infections of the external ear, with the ear infections of the external ear. Okay. So section four. It covers infections and inflammatory ear conditions. But primarily the rating schedule for this section is for that chronic external ear infection. Okay. Now for you to get a 10% rating for an external ear infection that is chronic, you have to have swelling, dry and scaly skin, drainage from the ear canal, itching and requires frequent and prolonged treatment. I don't know that I've ever seen an external otitis ear infection have all of those and that is a 10% rating. So that's not a for me. It's not a realistic thing to see in the clinic or for a disability rating thing to see in the clinic or for a disability rating.

Bethanie Spangenberg: 28:54

Section four continues to ask questions about infection-related conditions and that's to prompt another DBQ, for example, bone loss of the skull. You can get a disability rating if the ear infection goes into the bone behind the ear. That is what we call mastoiditis and sometimes with mastoiditis they have to go in and remove that section of bone because there is chronic infection in there. I have seen that a few times with patients who have. Normally it's not like something that occurs because of chronic otitis media, but it's something that occurs as like a random fluke. They get a really severe ear infection one time and it just decides to seed into the bone that's close to that ear infection and then they go in and they have to have part of it removed.

Bethanie Spangenberg: 29:49

Once you have mastoiditis or infection in that bone area, it's actually a pretty serious condition because it is so close to the brain. You start to worry about the infection causing issues with the area around the brain or even getting into growing to cause pressure in parts of the brain. So once you get mastoiditis or infection into the bone, it's a pretty significant condition where the individual has experienced, you know, some chronic issues to lead up to that. So that actually covers Section 4 for infection. Do you guys have any questions about that?

Ray Cobb: 30:32

No, is it hard to get those infections cleared up?

Bethanie Spangenberg: 30:37

If you don't treat the underlying issue absolutely with mastoiditis when it gets into the bone. If you catch it early enough, iv therapy can usually help. You always have to watch for recurrence in case the antibiotics didn't get all of the bacteria. But once it's into the bone and it's not responding, it can be I mean, that's where they go into removing the bone itself because they're having so much issue. To control it. It can be difficult at that point.

Bethanie Spangenberg: 31:15

So moving on to Section 5, on page 4, section 5 talks about surgical treatment. This is just a generic fill-in-the-blank. What kind of surgery? When did it happen? Was it left or right side? What was it for? And then I ask about any residuals related to surgery. And then we jump to page five.

Bethanie Spangenberg: 31:40

Page five and six are both dedicated to the physical examination, to the physical examination. Now I will say that for most of the ear conditions that are covered for the CBQ a physical examination is not required. So if I look at the veteran's file and I see that he has a diagnosis of Meniere's, the likelihood of me seeing anything related to that Meniere's by doing a physical exam is low, especially if they're not having active symptoms for that day. So because Meniere's affects the inner ear. I cannot see the inner ear by doing a physical examination. The only way that we can really assess the inner ear is by doing images and doing maneuvers or tests in order to capture or trigger those symptoms. So whenever a veteran goes in for their compensation and pension examination they may not have a physical exam at all for the ear conditions that they're claiming. So, for example, the first part to examine is the external ear. The external ear as it relates to Meniere's has no value for me to look at it, so they may not do the exam. Has no value for me to look at it, so they may not do the exam. The next section is for the ear canal. Again, for some of those inner ear conditions the canal does not play a role in that disease process, so they may not look into it. And then we have the tympanic membrane or the eardrum that the examiner is to look at. And there is an option here for the examiner to say let me read it word for word to you. It says let me see, oh, exam of tympanic membrane is not indicated, or exam of the ear canal is not indicated. So they have the option of marking that on the DBQ and moving on On page six, this is those specific maneuvers that I was talking about, that are tools used to help us suspect a diagnosis.

Bethanie Spangenberg: 34:10

So normally if a patient comes into the clinic and complains of dizziness and I'm suspecting some type of inner ear complaint, I will watch them walk, but they may not have an abnormal walk. Sometimes they may have some staggering that we talked about, but that's not always present for a compensation and pension exam or a visit into the clinic. Normally that's something that they say hey, I'm having trouble walking, I kind of fell into the wall at home or at work. That's normally what we are hearing in the clinic, not something that we see firsthand.

Bethanie Spangenberg: 34:51

There's a test called the Romberg test which has to do with the arm change during an exam. Basically the individual closes their eyes, they stick their arms out inside of them with their palms up and they just hold them there and sometimes we can see an arm start to drift. That is more used in the clinic for a neurologic condition than it really is for an inner ear condition. But it's on the DBQ and it's a tool that can be used to kind of support a diagnosis that may be found related to an inner ear condition.

Bethanie Spangenberg: 35:32

The next one is a Dix-Hallpike test and I'm not really going to explain that because it can be difficult, but it's a position change trying to trigger some of that dizziness that the patient may be experiencing that the patient may be experiencing. And then there's a limb coordination test where the patient can take their index finger and they touch the examiner's finger and then touch their nose and the examiner moves their finger and that patient has to touch the tip of that finger and their nose again. So some of these things you guys have made down in the clinic, these are just tools to help us kind of narrow down the diagnosis For compensation of pension purpose. They have no value but they are documented on the physical exam. So I think that's really to make the clinician feel better about discussing an inner ear or ear condition rather than coming in and asking about symptoms and then walking away. I really do, because it has no value when it comes to a rating decision.

Bethanie Spangenberg: 36:33

Any questions about the physical exam?

Ray Cobb: 36:38

No.

J Basser: 36:41

I've been through quite a few of them and you're right exactly what that is, yeah right, exactly what it is.

Bethanie Spangenberg: 36:47

Yeah, it's actually if um even like with someone that you're concerned with, um like their brain function, if you're concerned with a stroke or some type of dementia or alzheimer's, or even like a tumor, the testing that is done, some of the arm drift, or that Romberg test, the finger to nose those are pretty standard things, even with the TBI. If you have a concussion or we're in a motor vehicle accident, the examiner may do some of these similar examinations in the clinic to assess how the brain is working. And again, the inner ear is so close to the brain that we really have to use these as tools to support our clinical decision-making. So if we move on to the DBQ, we're looking at page 7. We're looking at section 7. It has to do with tumors and neoplasms. Since we've covered these DBQs, I really haven't laid heavy on the tumors and the neoplasms, mainly because the thought process for each area is about the same. So it has to do with whether it's malignant or benign and what kind of disruption that tumor or growth has created on the body. There's nothing specific in the rating schedule for tumors and what we call neoplasms or growth as it relates to the ear specifically, and if it was, I would break it down, but there's nothing specific to the ear conditions as it relates to any type of tumor or growth.

Bethanie Spangenberg: 38:30

Moving on to Section 8, we're actually on the home stretch when it comes to the DBQ. Section 8 is the blanket area for the clinician to discuss any other physical findings or complications that they want to discuss that they found during their time with the veteran. Also, the space there or the questionnaire regarding scars, which we have discussed previously. Section 9 on page 8. This is important. This is the diagnostic testing that has been done. There is a section in the CFR that talks about requiring objective tests in order to give a compensable rating for any type of inner ear disease. So if a veteran is claiming vertigo or the BPPV or MeniereS, they are going to have to provide the workup and the test that show the objective data that they have that condition. So that's important. And, rounding out the DBQ, on page 9, we're looking at other testing that may have been done for the veteran's condition.

Bethanie Spangenberg: 39:52

Section 10 is that functional impact. As always, I emphasize that you put any type of functional impact, any type of symptom that prevents you from doing your regular function at work or at home is important to document. As John previously asked about aid and attendance, you want to talk about those limitations that you have with the condition in your statement. The clinician may not always ask about what your functional impairment is. They may look at it and say, okay, well, the veteran has told me about all these symptoms. That's not going to keep him from working, that's not going to keep her from working, so they may mark no, that you don't have any functional impairment and move on. So as always, I emphasize, you need to put that information into a statement and supportive claim to go with your disability claim.

Bethanie Spangenberg: 40:53

The last two sections we have Section 11, which is remarks and open space for the clinician to make any comments, and then the last section, section 12, is the examiner's certification and their signature asking about you know their certification, their license number, things like that. Any questions about the EAR DBQ?

J Basser: 41:21

You heard your Latin clear.

Bethanie Spangenberg: 41:27

I would say that this DBQ is pretty straightforward. If the veteran goes in to talk with the clinician in person, they can be in and out the door in 30 minutes with this examination it would take the clinician maybe 45 minutes to an hour to do the DBQ and answer any type of medical opinion that would go with this exam request.

J Basser: 41:55

Well, you know, the most common I guess like the most common disability within the VA system, is public analysis right.

Bethanie Spangenberg: 42:02

Yes, absolutely Okay. So, Absolutely Okay, you know, I'm waiting for them to.

J Basser: 42:14

I wonder if they will ever change that?

Bethanie Spangenberg: 42:15

Because they have recently. If you look at the changes that the VA is trying to make as it relates to disability and disability ratings, is they're really trying to put objective material into these conditions and objective information because they don't want to believe the veteran and they feel like a lot of the conditions the veteran may be exaggerating. So if you look at the changes that they're making, that we've even talked about, is they're trying to objectify everything and they're trying to require that there are tests done or things to prove that they are suffering from these conditions. So tinnitus, that is one condition that is so common, especially in our military population, but there is no objective testing to prove that they have this condition. So I'm interested if they ever touch it?

Bethanie Spangenberg: 43:07

And if they do, what are they going to do?

J Basser: 43:13

I mean I can hear it. I may not be able to hear it, but I can hear it. And you know it's pretty terrifying. I mean I've seen it drive people to suicide.

Ray Cobb: 43:23

Yes.

J Basser: 43:25

So pretty bad stuff yes.

Bethanie Spangenberg: 43:28

It's actually interesting to see because tinnitus is one of those things that can affect how a person communicates and it can create a barrier between you know the veteran that has the condition and how they interact in day-to-day life and how they interact in day-to-day life.

Bethanie Spangenberg: 43:46

So I've said this before and I say this a lot to the people that I communicate with, is that if I didn't see it firsthand, I wouldn't believe it, and so a lot of the things that I watch my veterans suffer with I truly believe. That's why I do what I do is because as a young family, I don't feel like my husband should be suffering through some of the things that he's suffering with, and tinnitus and hearing loss is one of those things that you don't. I guess for myself I wouldn't have expected to deal with at this age, because we go to the soccer game my son's soccer game and he hears the crowd around him and he doesn't realize that he's as loud as he is and he will make comments and then my elbow goes into his side because, hey, you don't realize how loud you're saying these comments.

Bethanie Spangenberg: 44:46

You can't say those comments I get that a lot.

J Basser: 44:49

He gets those comments.

Bethanie Spangenberg: 44:49

I get that a lot.

J Basser: 44:50

It's the elbow, I get that a lot. I mean, yeah, you don't know how loud you are. You know because you don't know it. You know, and it's like my wife's father is, uh, almost completely deaf. He's a coal miner and, uh, he's had hearing aids and all this stuff for years, but occasionally he can hear. Okay, we were trying to get him headphones and watch TV and things like that. But he talks, just like you know, he's really loud. Pretty sad, but she looks at me like yes, yes, every time I say something Shut up, shut up.

Bethanie Spangenberg: 45:26

It's interesting too, because our children don't appreciate what is normal as far as a volume to talk, and so our children, I even have to remind our children like hey, don't talk so loud. So then I have my son, who doesn't talk loud at all because I keep telling everybody to stop talking so loud. And then you have my older daughter who talks really loud. I'm like, hey, you're too loud. And so there is no understanding in our household of what is socially acceptable volume in each you know social setting, and so it's kind of funny.

J Basser: 46:03

You know how it all, you know you got me thinking what is the VA going to do with these conditions? That there's no test to determine what it is. Cannabis is one, but you know the biggest one is mental health. There's no physical test for mental health. You know Well from what I've seen so far.

Bethanie Spangenberg: 46:22

what I've seen so far is they're not doing a good job and I have, you know, made it a point to be more proactive and watching when these conditions open for comment. I really feel like you know, being in this role or this very small area of expertise, is that I really need to use my voice to talk about some of what is clinically appropriate and their goal of requiring objective findings.

Bethanie Spangenberg: 46:54

We talked about the GERD changes and I don't agree with what they've done on the GERD changes, because there is other ways to prove objectively that an individual suffers from these conditions. And to require a medical condition to be so severe that it creates complications that are life-threatening complications before you compensate an individual, I think that's, I don't think that's fair, I don't think that's right, I don't think that's realistic and you know idealistic, I guess. How it affects the workforce or their occupational duties or their functional capacity, Well, GERD creates occupational impairments and there's the data and the studies out there and they don't use those as a reference.

Bethanie Spangenberg: 48:01

They want to use literature that is 20 years old and say well, this is how we're justifying it literature that is 20 years old and say well, this is how we're justifying it so yeah, and so I feel like I need to be more proactive in addressing some of their proposed changes.

J Basser: 48:20

Question on the group last week. Question on the group. Last week I was reading that someone said that a lot of VA providers know a veteran's got a condition and they're recording in their record but they will not actually make an official diagnosis of that condition. Do you know what makes them reluctant to do that? Are they afraid the vet's going to go out and file a claim for it, or what? I see that a lot.

Bethanie Spangenberg: 48:46

I can see it being that way. They're worried about getting tied up into the whole disability process. And so, you know some of the clinicians at the VA, they kind of get burnout on veterans pushing the latest and hottest issue. Veterans pushing the latest and hottest issue. You know, there's been times in the past where I've always, you know, encouraged those providers to just keep their head down and stay out of the mess, Just document the discussion that you've had and don't get tied up into what they are trying to do. You have to make what is clinically appropriate for your patient and not what a veteran may be pushing to do. And I think we talked about this briefly, about how the GERD changes are now going to push these veterans to want to see the GI specialist.

Ray Cobb: 49:43

And.

Bethanie Spangenberg: 49:43

I don't necessarily disagree with that as long as it's clinically appropriate. And I don't necessarily disagree with that as long as it's clinically appropriate. And so that's again. I tell the clinician.

Bethanie Spangenberg: 49:52

I know that it's stressful, I know it creates a lot of extra appointments in your workday, but keep your head down, stay out of the legal mess, document the discussion as you would any other time, and do what's clinically appropriate. You cannot allow the disability rating schedule and the political changes to impact your clinical decision-making. And it's hard to do, it can be overwhelming at times, bethany one thing I've noticed where I go.

Ray Cobb: 50:27

here the doctors are actually doing they're saying what needs to be said, but they're not putting down the diagnosis itself In the little square where it says your diagnosis. They leave that blank. Now, up above that, they're telling you know all the conditions, all the things that are going on, and then don't do that. And then when the guy goes and files his claim, they come back and say well, you didn't have a diagnosis for it, so there's a couple things that I've seen with that.

Bethanie Spangenberg: 51:02

So for us in the clinic and how it relates to disability, it can be not on the same page. They're not always on the same page. So for me, like in the clinic when I would do my charts or when I do my charts, there's so much you have to have for billing purposes. There's so much you have to have for billing purposes. And that's really where a diagnosis code, the diagnosis portion, so when it comes to a veteran having a diagnosis, it doesn't require that it is in a billing code, it requires that it's under the clinician's treatment plan. So there's a section under assessment and plan in the note that the clinician will line item the diagnosis and maybe after that diagnosis they will say their treatment plan. And so it can be difficult to kind of argue that between the clinician side and the legal side because they're not putting it in the diagnosis section for disability purposes. Are you following?

Bethanie Spangenberg: 52:44

what I'm saying yeah exactly All right the difference is that basically the note is a free text versus the billing is a formal code.

Bethanie Spangenberg: 52:57

So sometimes the clinician will put what is required for billing purpose and a formal code, but they will free text all the other diagnoses in the note. So, for example, I would see a patient who would have 23 diagnoses. I never put all 23 diagnoses into my insurance bill because the top three are the only ones that mattered. So I would click or insert two or three codes that would capture the billing for the insurance and then the other 19 diagnosis would be in my free text section of my note and so they don't correspond. And when you go to get your blue button records, the only ones that fall under the diagnosis section is what the clinician has put in for billing purposes. Now if you're talking about the clinician having a series of symptoms that's consistent with the diagnosis, you know, I would not want to believe that the clinician is trying to gatekeep that veteran from getting what is entitled to him. I wouldn't believe that's so. That I would believe is either clinician inexperience or they're requiring another visit to confirm the diagnosis.

J Basser: 54:14

Okay, Beth, you just learned something very important right there. Anytime you're looking at your notes and you're trying to see what's what, pay very special attention. It doesn't matter what is written in the upper part of the document. Go down toward the bottom and you'll see bottom and you'll see the assessment and you'll see the treatment plan. That is the bread and butter.

Bethanie Spangenberg: 54:33

Yes.

J Basser: 54:33

According to yes. So you know that's something you guys. It makes it easier to look at things when you guys so Well we'll get, if you're looking for something you'll find it. Go ahead, betsy.

Bethanie Spangenberg: 54:49

We'll get veterans that try to give us the discharge instructions as proof of treatment for a condition and we can't accept those as proof because it doesn't open or allow for us to see what the clinical thought process was and what the assessment and plan is. And so when somebody gives us those discharge instructions it's like okay, this is patient verbiage. So when somebody gives us those discharge instructions, it's like okay, this is patient verbiage. These discharge instructions are specifically targeted to a 10th grade level for that patient to understand what their diagnosis is and what they need to do to treat it. It has from a compensation and pension and medical expert side it has little to no value for us to understand what happened at that clinical visit. So we need to see that treatment record and what that clinician has put into their assessment and plan of the clinical record. So it has value not only for the claim and for the veteran to look at but also for the medical experts. So you really need to get those if you're wanting, you know, to capture a private opinion.

J Basser: 55:54

And, if need be, guys, you've got a situation like that and you don't think you have a diagnosis, you can look at it. It's always good to have a secondary backup plan just in case, and there's a company called Vow valid for vets. You can call up and send the information to them and join their portal with let's just let him look at your paperwork, see if you can't work out an independent medical opinion with her and her her team, because they're good at what they do well, thank you for the plug, and we're actually going into our 10th year and we're looking to celebrate 10 years in the year of 2025 that we've been doing what we do and from the team approach that sets us apart from everybody else.

J Basser: 56:43

That's what it takes. It takes a team to build it. It takes a team to build it. It takes a team to keep it going too. That's a lot of work, so that's good. I want you to give everybody your contact information, bethany, so in case anybody's listening out there and wants to contact you and maybe reach out and touch you and get an IMO, what's the best way to get a hold of you and the website, and I'm both. Tell me the best way to get a hold of you and the website.

Bethanie Spangenberg: 57:09

So our website is Valor V-A-L-O-R. The number four vet V-E-T dot com. You can plug it into Google close as you want, and our website will pop up, or you can plug it into the URL directly. There's a lot of information and tools there that you can use and view to see how we may be able to help you. It has a process there for you to understand how we work, and then you can always call us 888-448-1011, if you just have questions and want to talk to somebody. We have veterans on our team that have been with us for a while that can help you understand how we function and how we may be able to help you.

J Basser: 58:00

Well, that's a good one. That's pretty good. Reach out and touch them folks. If you need help, they're there to help. So it's, uh, you know it's a good thing. Plus, their rates are really, uh, really really competitive. They're not very expensive as far as doing things like that. They're, uh, you know, good. Imo is worth the weight in gold, you know, because a lot of these examiners don't want to give you a diagnosis. Of course they do have the diagnosis, but it's hard to get it out of them. It's kind of like squeezing blood out of a tomato. But other than that, we've got about a minute left. Bethy, I want to thank you for coming on again, as usual.

J Basser: 58:42

And we'll get together next month and we'll have another subject to talk about. I don't know what it is yet, but I'm sure you'll think of something good.

Bethanie Spangenberg: 58:51

Well, I actually have it in mind. I think we need to keep going with the ear conditions or the upper respiratory, I guess, ears, nose and throat Transition into sinusitis and rhinitis, which is a good one, okay, well, we'll stay with the anatomy of that situation and go that way.

J Basser: 59:11

Well, thank you for coming on, buddy, and I appreciate your help, man.

Ray Cobb: 59:14

Yeah, no problem, glad to be here and Bethany thanks Every time she's on. I learn a little something else about my own medical stuff, you know, and so it's a big help.

J Basser: 59:25

I put that on there every time she's in. I said join us, as I learn something every time Bethany appears on the show.

Ray Cobb: 59:31

Yeah.

J Basser: 59:31

Well, listen. That'll be it for today. This is John, on behalf of Ray and Bethany, and the Exposed that Radio Show will be signing off for now. You have been listening to the Exposed that Podcast. Any opinions expressed on the show are the opinions of the guest speakers and not necessarily the opinions of Expose that, exposethatcom or BlogTalkRadio. Tune in next week for another episode of the Expose that podcast. Thanks for listening.

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