(cell phone 240-506-1556)

To: All veterans

Date: 2015

From:

Topic: Special Monthly Compensation

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)

for Veteran benefits

Craig N. Bash, M.D.

Neuro-Radiologist
www.veteransmedadvisor.com

NPI or UPIN-1225123318- lic #--D43471

4938 Hampden lane, Bethesda, MD 20814
Phone: (301) 767-9525 Fax: (301) 365-2589
E-Mail: drbash@doctor.com

SMC
Special Monthly Compensation (SMC) is a way for the VA to compensate the most seriously
disabled veterans with benefits well above the 100% level for many non-economic factors
such as social inadaptability, loss of body part/ function and/or profound disability. The
sub-100% levels unitize about 2000 VA rating codes but the SMC codes utilize about 60
additional codes in incremental full/half steps (see short eligibility list at the bottom of this
note-courtesy of vet 101 web site) which go above 100% to maximal R-2 and T levels or
about a 300% level. These codes are used to rate patients for issues such as loss of
ability to perform activities of daily living (ADLs) like loss of ability to maintain clean
hygiene, dress/undress, speak, feed, toilet, and/or inability to protect self from the daily
hazards of life. There are only about 30,000 veterans rated at the 100% level and the
numbers of veterans in the maximal SMC category is thankfully even more exceedingly
small (in the 3000 range) as these veterans have maximal catastrophic injuries. With the
current surge of TBI injuries from the gulf wars (VA in 10/2015 estimated the number to
be 400,000) due to high quality body armor and medical care. With advanced point of
injury care soldiers are surviving with more and more serious injuries and thus the VA
benefits division of 20,000 employees has responded to large need for TBI injury benefits
with a relatively new SMC code specifically for TBI called: SMC T. Note worthy is the fact
the American public generously provides monetary benefits for the SMC T at the same
rate as SMC R2.
Overall, the higher level SMC codes contain about 60 different ways to rate catastrophically
injured veterans for major neurologic losses to the brain (TBI)/spinal cord (SCI) along with
loss of limbs, sight, hearing and speech. The non SMC rate schedule utilizes the concept
of the amputation rule- such that any region can not be rated for more than the maximum
allowed under an amputation for that region but the SMC codes are more liberal and thus
for example a head/brain with a TBI can be rated for both psychiatric and cognition
problems simultaneously. Analogously, the spinal cord can be rated for loss of 1 to 4
extremity use, loss bowel/bladder/sex functions -- also simultaneously. The rate of coassociated (co-mormid) spinal cord injury (SCI) and TBI injuries is on the order of 7080%, thus many of these patients enter into the SMC codes in combined ways with both
SCI and TBI inquires. ( n.b. Clinically the veteran health administration [VHA] has
intelligently developed poly-trauma centers whereby these TBI and SCI inquired patients
can rehabilitate in a unified setting.) Wither you have a spinal cord injury or a TBI injury
the VA codes maximally provide monetary benefits at the R-2 SMC level for spinal cord
injuries and SMC T for TBI.
Based on the discussion the 60 SMC codes are complex and as such it is known that even
experienced BVA judges carry a printed primer on SMC to use during live hearings as a sort of
intellectual crutch. Amazingly, a senior VA employee told me that that there are only a handful of
VA employers nationwide that fully understand the subtle ins and outs of all the 60 SMC codes.
Hence, when a veteran obtains a routine rating for any SMC issue the likelihood that that SMC
rating is imperfect is high due to the complexity of the SMC codes, the lack of knowledge of
these codes by any single rater and the lack of code knowledge by claims and pension (C and
P) physician examiner. The physicians lack of knowledge is especially problematic as the rater
depends on the physician to document the patients disabilities in line with the rating schedule.
Therefore, most staff VA physicians do not do a correct rating exam for SMC as they are not
trained in the SMC code system.

Adding complexity to the SMC coding process, the VA has started to use a nation wide
series of DBQ forms, which are not geared toward any specific SMC code. SMC codes, by their
nature, always involve an integration of ratings based on several DBQs, thus when a DBQ for
SMC is done it is usually inadequate.
For example, a standard spinal cord injury SMC code of SMC (O) or R-1 would require 5-6
DBQS forms to fully document the issues needed for an accurate rating. The physician is
usually lost in this process as he does not know which DBQs apply nor the relative importance
of organ system issues because the VA rate system is not in line with a physicians primary
training in medical analysis, which involves the SOAP (subjective objective assessment and
plan) note. Physicians training involve a format whereby the emphasis is on the patients
assessment/diagnosis followed by a plan for treatment.
I good review of the eligibility for each SMC codes is found here:
https://www.vets101.org/a/58/d1.aspx
And a good general over view of SMC is found here at the Purple Heart web site:
http://www.purpleheart.org/ServiceProgram/Training2012/10-M-%20SMC%20final.pdf
If the above SMC codes are not correctly assigned there is the opportunity to correct these
errors thru the clear and un-mistakable error (CUE) process, which requires full a record review
by a high level GS-13 rater called a DRO. Many blogs state that CUE process is impossible to
navigate and obtain a corrected rating- this is not true but the CUE process does depend on a
careful longitudinal review for the entire medical record. Such a review by a physician is
essential because the civilian medical sector utilizes 65,000+ ICD-10 payment diagnostic codes.
Hence, a physician is needed to analyze/interpret all old diagnostic codes and medical clinic
notes to look for analogous VA codes. In other words, the physician must in essence merge the
VAs 2000 regular codes and 60 SMC codes with the civilian ICD-10 codes in order for the DRO
to do a reversal of past ratings by way of a new staged rating. The CUE should really be a joint
work product between a DRO and an experienced physical due to the complexities of the
historical medical record which involves both a changing disease process which simultaneously
must also be merged with a time changing set of VA rating rules.
Recommendations:
1. All SMC patients should pursue an experienced administrative benefits representative and
obtain medical opinions for any SMC injury as this is a complex area and many benefits are
often over looked by inexperienced support staff.
2. All patients should have a private medical nexus opinion and exam with DBQ forms prior to all
SMC at the RO, DRO or BVA decision at any level.
3. All patients should go to an in-person hearing. In my experience the outcome of the cases is
more accurate with in-person hearings as the judge can ask the patient real time questions
which are based on the medical record and claims file.

4. In my experience, the best type hearing to go to is in Washington DC (The wait now for these inperson hearings are on the order of several months as the backlog of appeals claims is growing
in response to the VAs current affinity for the 3-4 sentence denial, which is reducing the backlog
by about 20,000 claims a month but of course these terse options are increasing the BVA
appeals backlogs.), the second best hearing is a video hearing and third is the travel board
hearing. The reason for my above opinions is that, again in my experience, the BVA Judges
have the most available time at the in-person BVA DC area hearing, they have the second most
time in the video hearings and they have least amount of time in the travel boards hearings. In
fact at most travel hearings the travel judge is scheduled for 11-12 hearings in a day, which
leaves a limited amount of time for each individual patients hearing testimony. (n.b The BVA
travel board routinely take 2-3 years to schedule whereas an in-person or video hearing could
occur in as few as 3-6 months)
FYI *** VA has a new policy of No Form No Benefit (NFNB) so please do the forms as
carefully as possible and use administrative accredited agent and use an experienced physician
for SMC DBQ forms for a maximally correct VA medial diagnostic code (rating).
Craig Bash M.D. Associate Professor
drbash@doctor.com cell 240-506-1556
Independent Veteran Medical Opinion (IMO)
Veteran Medical Nexus Opinion based on Veterans medical records for veteran benefits
Short list of SMC codes:
Eligibility for Specific Levels of SMC
To receive an SMC (k) award you must have one of the following:

Anatomical loss (or loss of use) of:

o One hand
o One foot
o Both buttocks (where the applicable bilateral muscle group prevents the individual from maintaining
unaided upright posture, rising and stooping actions)
o One or more creative organs used for reproduction (absence of testicles, ovaries, or the creative
organ, loss of tissue of a single breast or both breasts in combination) due to trauma while in the
service, or as a residual of service-connected disabilities
o One eye (loss of use includes specific levels of blindness)
Complete organic aphonia (constant loss of voice due to disease)
Deafness of both ears that includes absence of air and bone conduction

To receive an SMC (l) award you must have one of the following:

Anatomical loss (or loss of use) of:

o Both feet
o One hand and one foot
Blindness in both eyes with visual acuity of 5/200 or less

Permanently bedridden
Regular need for aid and attendance

To receive an SMC (m) award you must have one of the following:

Anatomical loss (or loss of use) of:

o Both hands
o Both legs at the region of the knee
o One arm at the region of the elbow with one leg at the region of the knee
Blindness in both eyes, having only light perception
Blindness in both eyes resulting in the need for regular aid and attendance

To receive an SMC (n) award you must have one of the following:

Anatomical loss (or loss of use) of both arms at the region of the elbow
Anatomical loss of both legs so near the hip that it prevents the use of a prosthetic appliance
Anatomical loss of one arm so near the shoulder that it prevents the use of a prosthetic appliance, along
with the anatomical loss of one leg so near the hip that it prevents the use of a prosthetic appliance
The anatomical loss of both eyes, or blindness in both eyes that includes loss of light perception

To receive an SMC (o) award you must have one of the following:

Anatomical loss of both arms so near the shoulder that it prevents the use of a prosthetic appliance
Bilateral deafness (both ears) rated at least 60% disabling, along with service-connected blindness
with visual acuityof 20/2000 or less in both eyes
Complete deafness in one ear or bilateral deafness rated at least 40% disabling, along with serviceconnected blindness in both eyes that includes loss of light perception
Paraplegia-paralysis of both lower extremities, along with bowel and bladder incontinence
Helplessness due to a combination of loss (or loss of use) of two extremities with deafness and blindness,
or a combination of multiple injuries causing severe and total disability

To receive an SMC (p) award you must have one of the following:

Anatomical loss (or loss of use) of a leg at or below the knee, along with the anatomical loss (or loss of use)
of the other leg at a level above the knee
The anatomical loss (or loss of use) of a leg below the knee, along with the anatomical loss (or loss of use)
of an arm above the elbow
The anatomical loss (or loss of use) of one leg above the knee and the anatomical loss (or loss of use) of
one hand
Blindness in both eyes, meeting the requirements listed for SMC (l), (m) or (n)

To receive an SMC (r) award you must:

Be receiving the maximum SMC (o) benefits and require:

o Aid and attendance, or
o Aid and attendance of another person without which you would require hospitalization, nursing
home care or other residential type care

To receive an SMC (s) (Housebound) award, you must either:

Meet all of the following:

o You have a service-connected disability rated at 100%

o
o

You have a qualifying, additional service-connected disability (or disabilities) that is completely
separate from the first disability and is independently rated at 60%
You are approved for VA disability compensation

OR

Be housebound:
o Your disabilities must directly cause you to be substantially confined to your home and the
immediate premises or, if you are in an institution, to the ward or clinical areas
o Also, it must be reasonably certain that your disability or disabilities and confinement will continue
for the rest of your life

To receive an SMC (t) award you must:

Need regular Aid and Attendance (A&A) for the residuals of (results of) Traumatic Brain Injury (TBI)
Not be eligible for a higher level of A&A under SMC (r)(2)
Need hospitalization, nursing home care, or other residential institutional care without in-home A&A

Eligibility for Aid and Attendance

Usually, you may qualify for regular Aid and Attendance (A&A) benefits based on any of the following
circumstances:
You need the regular help of another person to perform everyday living activities, adjust prosthetic devices,
or protect yourself from the hazards of your daily environment. Even if you are able to perform some of
those functions, you may still be able to qualify for A&A, because the VA will consider the particular
personal functions that you are unable to perform in connection with your condition as a whole.
You are bedridden because your disability (or disabilities) requires you stay in bed, not because of any
treatment you have had, such as surgery; OR
You are a patient in a nursing home because of a mental or physical incapacity; OR
You are blind, or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or have
concentric contraction of the visual field to 5 degrees or less.