VA/M-10 Manual for Gulf War Vete

VA/M-10 Manual for Gulf War Veterans (no longer published)

This publication is no longer in use and has been replaced by the 38 page VA Handbook 1303.2 for assessing Gulf War conditions and veterans. This VA/M-10 Policy Manual needs some revisions to include other (more detailed) evaluations and considerations and brought back into publication. Please keep a copy of this manual for future reference.

(Logo) Department of Veterans Affairs

ENVIRONMENTAL AGENTS SERVICE

Persian Gulf Program

M-10, Part III Veterans Health Administration

August 8, 1995 Washington, DC 20420

August 8, 1995 M-10, Part III

Department of Veterans Affairs

Veterans Health Administration

Washington, DC 20420

The Department of Veterans Affairs, Veterans Health Administration Manual M-10, “Envioronmental Agents

Service,” Part III, “Persian Gulf Program,” is published for the compliance of all concerned.

Signed by Mike Huges

for

Kenneth W. Kizer, M.D., M.P.H.

Under Secretary for Health

Distribution: RPC: 1323

Printing Date: 8/95

March 21, 1996 M-10, Part III

Change 2

iii

CONTENTS

CHAPTERS

1. PERSIAN GULF PROGRAM

2. PHASE I, PERSIAN GULF REGISTRY EXAMINATION

3. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL

4. PERSIAN GULF REFERRAL CENTERS

5. PERSIAN GULF REGISTRY SPECIFICALLY FOR SPOUSES AND CHILDREN OF

PERSIAN GULF WAR VETERANS

M-10, Part III March 21, 1996

Change 2

RESCISSIONS

The following material is rescinded:

1. Manuals

M-10, Part III, Chapter 1 and 2, dated December 7, 1992.

2. Directives

10-95-053

August 8, 1995 M-10, Part III

Chapter 1

1-i

CONTENTS

CHAPTER 1. PERSIAN GULF REGISTRY (PGR) PROGRAM

PARAGRAPH PAGE

1.01 Purpose ........... 1-1

1.02 Background ...... 1-1

1.03 Authority and Healthcare Services Provided ................................................................................... 1-2

1.04 Health Evaluation ............................................................................................................................. 1-3

1.05 Exceptions to Services .................................................................................................................... 1-3

1.06 Responsibilities 1-4

1.07 Media and Other External Contacts.................................................................................................. 1-4

1.08 Special Health Needs of Persian Gulf Female Veterans ................................................................. 1-5

M-10, Part III August 8, 1995

Chapter 1

1-ii

RESCISSIONS

The following material is rescinded:

1. Manuals

M-10, Part III, Chapter 1, dated December 7, 1992.

August 8, 1995 M-10, Part III

Chapter 1

1-1

CHAPTER 1. PERSIAN GULF REGISTRY (PGR) PROGRAM

1.01 PURPOSE

a. This chapter provides procedures to establish a Persian Gulf Registry (PGR) Program at all Department of

Veterans Affairs (VA) health care facilities for concerned participants of “Operation Desert Shield /Storm.”

1.02 BACKGROUND

a. According to the Department of Defense (DOD) approximately 690,000 American servicemen and women

were involved in the Persian Gulf War. There may be a substantial number of troops actually exposed to unignited

petroleum and/or smoke from the sabotage of Kuwaiti oil wells by retreating Iraqi forces as well as other industrial

and environmental hazards.

b. Establishment of a PGR will assist VA in initiating a program to identify possible diseases which may result

from service of United States (U.S.) military personnel in certain areas of Southwest Asia (see par. 2.02). These

diseases may be endemic to the area or due to hazardous exposures, including heavy metals. Furthermore, air

pollutants, i.e., carbon monoxide sulfur oxides, hydrocarbons, particulate matter, and nitrogen oxides, singly or in

combination, can cause chronic as well as acute health problems.

(1) These health problems may include:

(a) Chronic bronchitis,

(b) Chronic obstructive pulmonary disease,

(d) Bronchial asthmas, and

(e) Lung cancer.

NOTE: U.S. veterans who served in the Persian Gulf theatre of war are henceforth in M-10. Part III, referred to

as Persian Gulf veterans.

(2) Persian Gulf veterans have reported a wide variety of symptoms and exposures as a consequence of

Persian Gulf service. These include, but are not limited to exposure to:

(a) Oil, smoke and other petrochemical agents;

(b) Leishmaniasis (Sand flies);

(d) Depleted Uranium (DU);

(e) Inoculations (Anthrax, botulism, etc.);

(f) Pesticides;

(g) Diesel and jet fuels and other petrochemicals and solvents;

(h) Chemical Agent Resistant Compound (CARC) paint;

(I) Chemical and/or biological warfare agents; and

M-10, Part III August 8, 1995

Chapter 1

1-2

(j) Contaminated food and water obtained in the Persian Gulf.

(3) The following symptoms have been reported by a number of Persian Gulf veterans:

(a) Gastrointestinal problems;

(b) Flu-like conditions;

(d) Sinus congestion, post nasal drip;

(e) Joint pains and/or muscle soreness;

(f) Hair loss;

(g) Headaches;

(h) Memory loss;

(i) Chronic fatigue;

(j) Thickened saliva;

(k) Loose teeth, sore and/or bleeding gums;

(l) Dizziness, vertigo;

(m) Sleep disturbance; and

(n) Other symptoms and/or exposures.

(4) During the examination process, these exposures and health conditions will be identified and documented

in the Consolidated Health Record (CHR) and VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet.

c. The creation of a registry containing medical and other data on exposed veterans will signal VA’s

commitment to address questions concerning possible future effects of air pollutant exposure, other environmental

agents, and serve as the basis for future medical surveillance. NOTE: VA is in the process of requesting

support for future computerization of this registry.

1.03 AUTHORITY AND HEALTH CARE SERVICES PROVIDED

Title 38, United States Code (U.S.C.) Chapter 17, Section 1710, provides for health care only, and a

determination that the veteran is eligible for such care does not constitute a basis for service-connection or in any

way affect determinations regarding service-connection.

a. Health care services will be provided to veterans who while serving on active duty in the Southwest Asia

theater of operations during the Persian Gulf War may have been or were exposed to a toxic substance or

environmental hazard. Verification of service in the Persian Gulf during the Persian Gulf era (August 2, 1990 - no

ending data established by law) will be required. Inasmuch as VA presumes that a veteran was exposed to a toxic

substance or environmental hazard during any service in the Persian Gulf, a verified claim of such in-country

service constitutes the required contention of exposure and establishes eligibility for medical care within these

provisions.

b. Authorized health care services are limited to:

August 8, 1995 M-10, Part III

Chapter 1

1-3

(1) Hospital, nursing home care and outpatient care in VA facilities on a pre- or post-hospitalization basis or to

obviate a need for hospitalization.

(2) Such health care services will be provided without regard to the veteran’s age, service-connected status or

ability of the veteran to defray the expenses of such care.

(3) Veterans furnished outpatient care under this authority will be accorded priority ahead of most other non

service-connected veterans and equal to former Prisoners of War who are receiving care for non serviceconnected

conditions.

(4) Congress made it clear that this authority provides for health care only, and that a determination that the

veteran is eligible for such care does not constitute a basis for service-connection or in any way affect

determinations regarding service-connection.

NOTE: Health care services may not be provided under this authority for the care of conditions which

are found to have resulted from a cause other than the specified exposures.

1.04 HEALTH EVALUATION

a. Veterans claiming health conditions related to exposure to toxic substance or environmental hazard will be

evaluated clinically by means of a physical examination and appropriate diagnostic studies (see Ch. 2, App. 2B).

Where findings reveal a condition requiring treatment, the responsible staff physician shall make a determination

as to whether the conditions resulted from a cause not related to Persian Gulf Service.

b. In making this determination, the physician will consider the following types of conditions which are not

ordinarily considered to be due to toxic substances or environmental hazards:

(1) Congenital or developmental conditions, e.g., spina bifida, scoliosis.

(2) Conditions which are known to have existed before the Persian Gulf.

(3) Conditions resulting from trauma, e.g., deformity or limitation of motion of an extremity.

(4) Conditions having a specific and well-established etiology; e.g., tuberculosis or gout.

(5) Common conditions having a well-recognized clinical course, e.g., inguinal hernia or acute appendicitis.

1.05 EXCEPTIONS TO SERVICES

a. Although the types of conditions listed in paragraph 1.04 are not ordinarily considered to be due to a toxic

substance or environmental hazard, if the staff physician finds that a veteran requires care under this provision for

one or more of those conditions, the physician should seek guidance from the Chief of Staff (COS) and the

Veterans’ Registry Physician (VRP) regarding the authorization for treatment.

b. The decision and its basis will be clearly documented in the medical record or chart by the VRP.

c. Veterans who are not provided needed medical care under these provisions may be furnished care if they

are eligible under other statutory authority.

d. All non service-connected Persian Gulf veterans who respond affirmatively to the exposure question are

means tested before being seen by a physician.

M-10, Part III August 8, 1995

Chapter 1

1-4

1.06 RESPONSIBILITIES

a. A PGR will be established modeled after the Agent Orange and Ionizing Radiation Registries. All VA facility

staff are to be alerted of the PGR through appropriate internal communications, e.g., medical center memoranda

providing names, locations, and office telephone numbers of the Veterans’ Registry Physician (VRP) and the

Veterans’ Registry Coordinator (VRC).

(1) The PGR is the responsibility of VA Central Office Environmental Agents Service (EAS), in coordination

with:

(a) VRPs;

(b) VRCs; and

(2) It will consist of medical examinations and other data of concerned Persian Gulf War participants. The

PGR will be the most effective means of identifying such concerned veterans.

b. The EAS has the responsibility to develop, coordinate, and monitor Veterans Health Administration (VHA)

activities relating to the Persian Gulf issue. All policy and clinical questions relating to the identity of possible

diseases which may result from service of U.S. (United States) military personnel in certain areas of Southwest

Asia should be referred to EAS.

c. The VRP and VRC at each VA facility will assume respective responsibility for coordinating the medical and

administrative aspects of the registry. The VRP, VRC, and other medical center staff, will play a key role,

beginning with the initial contact in:

(1) Providing registry participants with medical examinations and necessary treatment where medically

indicated for eligible veterans;

(2) Advising veterans of examination results; and

(3) Submitting properly completed code sheets to the AAC.

d. There will be a time lapse between the date of examination and the processing of examination results.

Accordingly, analyses used in speeches or presentations should be qualified to avoid misleading or misinforming

the audience.

1.07 MEDIA AND OTHER EXTERNAL CONTACTS

a. Media Contacts. Reports of Contact from various media sources (e.g., radio, television, newspapers, etc.)

concerning PGR Program activities will be referred by phone to the facility Public Affairs Officer. Interviews should

not be given unless approved by the medical center Public Affairs Officer who may appropriately coordinate

response with the regional VA public affairs representative.

b. Contacts to Advise Centers of “Special Cures” for Persian Gulf-Related Illnesses. Medical centers

can expect, on occasion, to be contacted by private sector physicians, researchers, and the general public with

information regarding “quick cures” for Persian Gulf-related illnesses. Such individuals should be advised that:

(1) There are medically accepted mechanisms to introduce new clinical treatments;

(2) All new treatments suggested must be reviewed by a formally designated and staff Human Subjects

Review Committee;

(3) It is important to have independent confirmation of treatment efficacy;

August 8, 1995 M-10, Part III

Chapter 1

1-5

(4) Provisions exist to permit the originator of new therapies to retain professional credit and be appropriately

compensated; and/or

(5) The individual might want to consider presenting the “new approach” at a VA or medical school Grand

Rounds or Staff Review Committee meeting.

1.08 SPECIAL HEALTH NEEDS OF PERSIAN GULF FEMALE VETERANS

VHA is committed to providing for the physical and psychological treatment needs of women veterans who

have been sexually or physically abused, or engaged in combat.

a. The VRP should be aware of and sensitive to the needs of Persian Gulf women veterans who were:

(1) Raped;

(2) Otherwise sexually assaulted;

(3) Sexually harassed;

(4) Combatants during military service; or

(5) Prisoners of War.

b. This can lead to long-term psychiatric and psychosomatic sequelae. When a problem is detected,

appropriate counseling and psychotherapy must be provided.

NOTE: Since this is a highly specialized area, it may be necessary to make appropriate referral to other

VA or private sector providers. This should be reported on the CHR as well as under Item 32, Part II of

VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, Phase I.

August 8, 1995 M-10, Part III

Chapter 2

2-i

CONTENTS

CHAPTER 2. PHASE I, PERSIAN GULF REGISTRY (PGR) EXAMINATION

PARAGRAPH PAGE

2.01 Purpose ................. 2-1

2.02 Eligibility Criteria .... 2-1

2.03 Program Management ........................................................................................................................... 2-2

2.04 Responsibilities ...... 2-2

2.05 Consolidated Health Report (CHR) ....................................................................................................... 2-5

2.06 Incarcerated Veterans ........................................................................................................................... 2-5

2.07 Veterans with other than Honorable Discharges ................................................................................... 2-5

2.08 Active Duty Military Personnel ............................................................................................................... 2-5

2.09 Updating VRP and VRC Appointments ................................................................................................. 2-6

2.10 Report to AAC ........ 2-6

APPENDICES

2A Definitions and Acronyms ......................................................................................................................... 2A-1

2B Protocol for Conducting the Physical Examination and Ordering Diagnostic Studies .............................. 2B-1

2C Sample and Instructions for Completing VA Form 10-9009A (July 1995), Persian Gulf Registry

Code Sheet, Phase I, Part I, II, and III .................................................................................................. 2C-1

2D Reporting Requirements .......................................................................................................................... 2D-1

2E Instructions and Sample and for Completed VA Form 7252, Transmittal Form

for Use in Shipment of Tabulated Data ................................................................................................. 2E-1

2F Instructions and Sample Format for Completion of Bi-monthly Report of Persian Gulf War

Veterans Registry Examinations (RCS 10-0875) .................................................................................. 2F-1

2G Examples of Persian Gulf Registry Follow-up Letters ............................................................................. 2G-1

M-10, Part III August 8, 1995

Chapter 2

2-ii

RESCISSIONS

The following material is rescinded:

1. Manuals

M-10, Part III, Chapter 2, dated December 7, 1992.

August 8, 1995 M-10, Part III

Chapter 2

2-1

CHAPTER 2. PHASE I, PERSIAN GULF REGISTRY (PGR) EXAMINATION

2.01 PURPOSE

This chapter sets forth clinical and administrative policies related to the maintenance of Veterans Health

Administration’s (VHAs) Persian Gulf Registry (PGR) Program for physical examinations of concerned veterans.

2.02 ELIGIBILITY CRITERIA

The Department of Veterans Affairs (VA) will provide a PGR examination to veterans who served on active

military duty in Southwest Asia during the Persian Gulf War between August 2, 1990, and the official termination

date (to be established). Active duty military personnel who served in Southwest Asia are encouraged to

participate in the PGR program, (see par. 2.07).

a. This would include service in one or more of the following areas:

(1) Iraq;

(2) Kuwait;

(3) Saudi Arabia;

(4) The neutral zone (between Iraq and Saudi Arabia);

(5) Bahrain;

(6) Qatar;

(7) The United Arab Emirates:

(8) Oman;

(9) Gulf of Aden,

(10) Gulf of Oman; and

(11) Waters of the:

(a) Persian Gulf,

(b) Arabian Sea; and

NOTE: Medical Administration Service (MAS) should be consulted to determine whether each veteran

applying for this examination meets pertinent eligibility requirements.

b. Eligible Persian Gulf veterans applying for treatment in a VA medical center and/or outpatient clinic should

be encouraged to undergo an initial (i.e., “first-time”) PGR examination. The protocol for conducting the physical

examination and ordering diagnostic studies is contained in Appendix 2B.

c. Veterans should be advised that examination or treatment does not constitute a formal claim for

compensation.

(1) Although the results of a PGR examination may be used to support a compensation claim, the examination

will not in and of itself be considered such a claim.

M-10, Part III August 8, 1995

Chapter 2

2-2

NOTE: If a compensation examination is performed for a Persian Gulf War veteran and the veteran

requests inclusion in the PGR, it is not necessary to schedule an additional registry examination as long

as the information is sufficient to adequately complete the PGR code sheet for submission to the Austin

Automation Center (AAC).

(2) Veterans who wish to submit a claim for conditions possibly related to Persian Gulf service should do so via

the normal claims process through a Veterans Benefits Counselor (VBC) at the nearest VA medical center or

regional office.

2.03 PROGRAM MANAGEMENT

For current information and program activities, Veterans’ Registry Physicians (VRPs), Veterans’ Registry

Coordinators (VRCs) and MAS employees should receive and familiarize themselves with quarterly mailouts and

various materials distributed by VA Central Office. In addition, all program officials should attend the periodic

Environmental Agents Service (EAS) conference calls from VA Central Office.

2.04 RESPONSIBILITIES

The VRP, or designee, VRC and MAS staff play a significant role in determining the perceptions veterans have

concerning the quality of VA health care services and of their individual treatment by VA health care providers.

a. VRP Responsibilities. The VRP, or designee, is responsible for clinical management of the veteran on the

registry and will serve as their primary health care provider unless another has been assigned. The VRP serves in

an advisory capacity for the administrative management of the program. The VRP should be the person to

discuss with the patient the results of the examination(s) as well as providing follow-up visits and/or possible

referrals to other tertiary medical centers or Persian Gulf Referral Centers (PGRC). Major essential

responsibilities include:

(1) Counseling the veteran as to the purpose of the physical examination;

(2) Providing focused initial examination and continuum of care to those symptomatic veterans experiencing

multiple symptoms after their Persian Gulf experience;

(3) Conducting and documenting the physical examination in the medical record or Consolidated Health

Record (CHR) at the time of the visit;

(4) Providing a complete medical history including:

(a) Family;

(b) Occupation;

(d) Civilian exposure to possible toxic agents;

(e) Psychosocial condition; and

(f) Review of systems.

(5) Completing Part II (Phase I) and III (Phase II) of VA Form 10-9009A (July 1995), Persian Gulf Registry

Code Sheet, and reviewing Part I and completing that section, if necessary.

August 8, 1995 M-10, Part III

Chapter 2

2-3

August 8, 1995 M-10, Part III

Chapter 2

APPENDIX 2A

2A-1

(a) Reviewing the code sheet to further ensure the form’s completeness, the clinical examiner will

review the code sheet and, if necessary, obtain and record any missing information from the veteran.

NOTE: Code sheets should be transmitted to AAC no later than 25 working days after initial examination.

(b) Inquiring whether any of the veteran’s natural children have any birth defects and noting in Item 22

and the CHR.

(6) Reviewing records of every Persian Gulf veteran examined to ensure that a complete physical

examination was performed and documented;

(7) Personally discussing with each veteran the findings of the physical examination and completed

diagnostic studies. The interview will be conducted in such a way as to encourage the veteran to discuss

any health concerns, as well as concerns expressed by family members;

(8) Personally discussing each veteran’s need for a follow-up examination either recommended by

VRP or requested by the veteran;

(9) Documenting these discussions and/or findings in each veteran’s CHR.

(10) Encouraging the veteran to contact VA medical center to include additional diagnoses in CHR and

PGR if the veteran is subsequently diagnosed with a significant health problem by a non-VA physician.

This new diagnosis must be submitted under non-VA physician’s signature and on official letterhead. A

code sheet identified as, follow-up examination, Type C, will be completed with this diagnosis and

subsequently forwarded to AAC for inclusion in PGR.

(11) Preparing and signing a follow-up letter to each veteran explaining the results of the examination

and associated laboratory tests. NOTE: Sample follow-up letters are provided in Appendix 2G.

(a) These letters are to be mailed to the veteran within 2 weeks of the initial examination appointment

and follow-up examination when a new diagnosis is determined. The only exception to this timeframe will

be when a consultation at a specialty clinic is requested as part of the initial examination process. This

exception suspends, but does not remove the requirement for the follow-up letter. The follow-up letter is

to be sent no later than 2 weeks after the consultation.

(b) A copy of this dated and signed letter will be filed in the veteran’s CHR.

Inappropriate wording could unduly alarm or confuse the veteran. A great deal of sensitivity and care

should be exercised in the preparation of this correspondence.

(d) The letter will explain that:

1. If the veteran who was examined has no detectable medical problems, the follow-up letter should so

indicate and suggest that the veteran contact the nearest VA health care facility if health problems appear

later.

2. If it is determined upon examination that the veteran does have medical problems, it is not

necessary to specify the problems in the letter.

3. The veteran should be advised in the letter that the recent examination indicated a health condition

or problem which may require further examination and/or treatment.

4. If the veteran is eligible for VA medical treatment, the letter should so advise and recommend that

the veteran seek follow-up medical care at the VA medical facility.

M-10, Part III August 8, 1995

Chapter 2

APPENDIX 2A

2A-2

5. If the veteran is not eligible for treatment, the letter should so advise and recommend that the

veteran seek appropriate medical care elsewhere.

6. The examination does not automatically initiate a claim for VA benefits. For information relating to

claims, refer the Persian Gulf veterans to a VBC at the nearest VA medical center or regional office.

7. The results of the examination will be maintained by VA and will be available for future use as

needed; and

8. If the veteran changes place of residence, the veteran should provide the new address to the VRC

to be recorded on a computerized record or card file and included on a corrected code sheet (Type "E"

examination code) for submission to AAC.

b. Veterans’ Registry Coordinator (VRC) Responsibilities

(1) The VRC is responsible for the administrative management of the program, including:

(a) Scheduling of appointments;

(b) Monitoring timeframe compliance;

(d) Collecting data for reporting purposes.

(2) The VRC is responsible for the following:

1. Scheduling. Facilities should make every effort to give each veteran a PGR examination within 30

days of the request date. If numerous consultations are required, all of these should be scheduled on the

same day, whenever possible, so that the veteran will not be unduly inconvenienced. When it is not

possible to provide all consultations on the same day, the VRC/scheduler should work with the veteran to

minimize disruptions in the veteran’s life. If a medical center fails to meet the time standard of 30 calendar

days from date of request, the medical center Director in coordination with the Regional Office Director

shall work together to explore all alternatives; i.e., referrals to other VA facilities, additional staff hours to

perform these examinations; and the possibility of the use of fee-basis sources or contracting out some or

all examinations with volume health care providers, to bring the medical center in line with the time

standard.

2. Disseminating Information. It is important that each Persian Gulf veteran be fully advised of the

PGR examination. Facility staff are encouraged to fully communicate all aspects of the PGR examination

by any appropriate means. The following alternatives might be considered:

a. Upon distribution by VA EAS, provide each Persian Gulf veteran reporting to the outpatient area,

with a VHA Headquarters (131) handout, “VA Persian Gulf Veterans’ Illnesses, Questions and Answers,”

Information Bulletin IB 10-41, describing the purpose of the examination and its limitations. This can be

further clarified by the examining physician prior to and during the course of the physical examination.

b, VRCs will also provide each veteran with a brief oral explanation of the purposes of the PGR and

the examination process and respond to any questions the veteran might have. This can be

accomplished during the VRCs initial contact with the veteran.

c. Computerized Record or Card File. A computer record or card file will be established to include data

on all registry participants. Each computer record or card file should include veteran’s full name, address,

telephone number, date of birth, Social Security Number (SSN), date of initial examination and date(s) of

subsequent follow-up examination(s). NOTE : This record will support the statistics included in the Bimonthly

Report of Persian Gulf War Veteran Registry Examinations (RCS 10-0860). In addition to other

information updates, every effort should be made by the VRC to maintain the veteran’s current address in

August 8, 1995 M-10, Part III

Chapter 2

APPENDIX 2A

2A-1

the computer record or card file for outreach purposes. VHA Headquarters is in the process of

establishing a VA system-wide computerization of this card file.

3. Code Sheet Completion

a. The VRC, or designee, will complete Part I of VA Form 10-9009A, and will ensure that all

information is entered on the code sheet before the veteran is referred to the clinician for the examination.

b. The VRP will complete Part II and III of VA Form 10-9009A. (Refer to instructions and sample code

sheet in App. 2C).

c. In the event that a veteran requests a PGR examination but does not wish to be included in the

registry database, a registry examination should be performed. Item 32, “Remarks,” should indicate the

current date and note that the veteran chose not to participate in the registry. This code sheet should be

filed in veteran’s CHR. Do not submit this code sheet to the AAC.

2.05 CONSOLIDATED HEATH RECORD (CHR)

The VRC will ensure that a CHR on each registry participant is created if one does not already exist.

a. All Persian Gulf veterans participating in the registry will have a VA Form 10-9009B (Persian Gulf

Identification Sticker) affixed to their CHR. VA Form 10-9009B should be affixed to the front of the record

in the lower left-hand corner of the “service connected” block.

b. These Persian Gulf registry records are subject to the same retention and disposition policies as

other medical record files, i.e., Records Control Schedule 10-1.

2.06 INCARCERATED VETERANS

VA medical facilities can provide assistance to penal authorities or institutions, which agree to provide

examinations to veterans, without reimbursement from VA, for purposes of entry in the PGR.

a. Copies of directives, code sheets, etc., will be provided to penal institutions upon request.

b. Penal authorities must be advised at the time of such requests that the results of the examinations

provided at their institutions must be returned to the VA medical facility of jurisdiction for inclusion, in the

veteran’s behalf, in PGR and in the veteran’s CHR.

2.07 VETERANS WITH OTHER THAN HONORABLE DISCHARGES

The requirements of M-1, Part I, Chapter 4, applies to veterans with less than honorable discharges

applying for PGR examinations.

2.08 ACTIVE DUTY MILITARY PERSONNEL

When active duty members of the uniformed services apply to VA facilities for a PGR examination,

Department of Defense (DOD) must authorize and provide the appropriate DOD Form 2161, Referral for

Civilian Care, requesting this examination or provide services under existing DOD/VA sharing agreement.

The requirements of M-1, Part I, Chapter 15, regarding the authorization and billing from the appropriate

branch of service will apply. Facilities should also reference the current directive providing the interagency

billing rates.

a. Procedures for processing the examination are the same as those for a veteran participating in this

program.

M-10, Part III August 8, 1995

Chapter 2

APPENDIX 2A

2A-4

b. A military facility may perform the PGR examination according to VA instructions or the

corresponding military instructions. NOTE: DOD has established a Persian Gulf Hot Line, telephone

number 1-800-796-9699 to direct active duty personnel to military hospitals for medical examinations and

provide other related information. An additional telephone number has been established (1-800-472-

6719) for Persian Gulf War veterans to call with their recollection of "incidents" that might be related to

health problems.

c. Military facilities may obtain the pertinent VA administrative issue and appropriate forms from the

nearest VA facility. The VA Medical Center, 50 Irving Street, N.W., Washington, DC 20422, Attn:

Persian Gulf Coordinator (136), is the processing center for all active duty members of uniformed services

stationed overseas. Military facilities will complete code sheets with exception of the following which will

be filed in by VA coding clerks:

Blocks Code Identifier

Part I 2 to 7 Facility number and suffix

137 to 141 County and State

d. Military facilities will provide completed copies of the code sheet, physical examination, laboratory

tests, etc., to the nearest VA medical center or outpatient clinic. The VRC will:

(1) Prepare a colored card (or computerized facsimile) for the file with similar data as for a veteran

and label the card “Active Duty”;

(2) Complete the code sheet to include facility number/suffix, if applicable, county and state codes.

(3) Submit code sheet to the VA Office of Financial Management, AAC, 1615 Woodward Street,

Austin, TX 78722-0001, in accordance with instructions;

(4) Establish a CHR if one does not already exist and file the PGR examination in this folder; and

(5) If requested, and only with written authorization (release of information) from active duty member,

VA may supply a copy of these medical records to the military facility.

2.09 UPDATING VRP AND VRC APPOINTMENTS

Separate listings of VRPs and VRC's are maintained within EAS.

a. In an effort to keep these listings current, facilities are required to notify the EAS of any changes in

the status of appointments of VRP's and/or VRC's at their respective facilities.

b. As changes in designation occur, submit in writing the name, title, mail routing symbol, FTS and

commercial numbers including area code, to the VRC (103A), EAS, VA Central Office, 810 Vermont

Avenue, N.W., Washington, DC 20420 (Facsimile Number FTS 700-565-7572). NOTE: In order to

provide current Persian Gulf information to concerned VA Registry Staff, it is important that any changes

in designation of VRPs or VRCs at VA facilities be provided to VA Central Office (103A) as they occur.

2.10 REPORT TO AAC

The PGR report should be prepared monthly and submitted to the AAC as per instructions contained in

Appendix 2D:

a. VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, and VA Form 7252, (originally 30-

7252) Transmittal Form for the Use in Shipment of Tabulating Data, should be prepared monthly and

August 8, 1995 M-10, Part III

Chapter 2

APPENDIX 2A

2A-1

submitted to AAC as per instructions contained in Appendix 2D. NOTE: These code sheets should be

submitted, based on the following schedule, but no later than 25 working days following initial examination.

b. The schedule of mailing dates is:

(1) Region 1 -- 6th of month;

(2) Region 2 -- 10th of month;

(3) Region 3 -- 14th of month; and

(4) Region 4 -- l8th of month.

March 21, 1996 M-10, Part III

Change 2

Chapter 2

APPENDIX 2A

2A-3

DEFINITIONS AND ACRONYMS

1. AAC - The Office of Financial Management, Austin Automation Center (AAC) was formerly the Data

Processing Center in Austin, TX. It is the location of the computerized registry for code sheet collection

and database entry.

2. AMIS - Automated Management Information System.

3. ANA - Anti-Nuclear Antibody.

4. BAER - Brainstem Auditory Evoked Response.

5. CAPS-PTSD - Clinical Administered-Post Traumatic Stress Disorder.

6. CARC - Chemical Agent Resistant Compound paint.

7. CBC - Complete Blood Count.

8. CHR - Consolidated Health Record - A file containing medical records relating to patient identity,

diagnosis, prognosis or treatment at VA facility.

9. CPK - Creatine Phosphokinase.

10. CT - Computed Tomography.

11. D.O. - Doctor of Osteopathy.

12. DOD - Department of Defense.

13. DOD Form 2161, “Referral for Civilian Care.”

14. DSM-III-R - Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised.

15. DU - Depleted Uranium.

16. EAS - Environmental Agents Service - EAS (103A), VA Central Office, has the responsibility to

coordinate and monitor all VHA activities, research and otherwise, relating to the Persian Gulf issue.

17. ECG - Electrocardiogram.

18. EEG - Electroencephalogram.

19. EGD - Esophagastroduodenoscopy.

20. EMG - Electromyogram.

21. ENG - Electronystamogram.

22. Examinations

a. Initial. The first physical examination which is completed and sent to the AAC for the purpose of

entering a veteran into the Persian Gulf Registry system.

b. Follow-up. Examination performed subsequent to the initial (first) examination.

M-10, Part III March 21, 1996

Change 2

Chapter 2

APPENDIX 2A

2A-4

23. Facility - Any VA entity which provides Persian Gulf Registry examinations to Persian Gulf veterans.

24. GI - Gastrointestinal.

25. GYN - Gynecology.

26. HcT - Hematocrit.

27. HgB - Hemoglobin.

28. HIV - HumanImmuno-deficiency.

29. IB-10-41 - VA Information Bulletin entitled “Persian Gulf Veterans’ Illnesses, Questions and Answers.”

30 ICD-9-CM - The International Classification of Diseases, Clinical Modification, 9th Edition provides

standardized classification of diseases.

31. IgG - Oligoconal.

32. KIA - Killed in Action.

33. KTO - Kuwait Theater of Operations.

34. LDH - Lactic Acid Dehydrogenase.

35. LP - Lumbar Puncture.

36. MAS - Medical Administration Service.

37. MIA - Missing in Action.

38. MOS- Military Occupational Specialty.

39. M.D. - Doctor of Medicine.

40. MRI - Magnetic Resonance Imaging.

41. MSLT - Multiple Sleep Latency Test.

42. NCV - Nerve Conduction Velocity.

43. O&P - Ova and Parasites.

44. P.A. - Physician’s Assistant.

45. PFT - Pulmonary Function Test.

46. PGR - Persian Gulf Registry - The PGR is a computerized index of veteran participants, is managed

centrally by the EAS in VA Central Office. The coded findings of Persian Gulf Program physical

examinations and related diagnostic results are entered into a database by the AAC.

47. PGRC - Persian Gulf Referral Centers - Selected tertiary VA Medical Centers (Birmingham, AL,

Houston, TX; , Washington, DC; and West Los Angeles, CA), with clinical and academic expertise in such

areas a

September 14, 1995 M-10, Part III

Chapter 2

Change 1

APPENDIX 2A

2A-3

pulmonary and infectious diseases, immunology, neuropsychology, and toxicology, where medical assistance is

provided for those Persian Gulf veterans with symptoms which defy explanation.

48. Plt - Platelet.

49. PPD - Purified Protein Derivative.

50. PTF - Patient Treatment File.

51. PTSD - Post Traumatic Stress Disorder.

52. Persian Gulf Area of Service. For eligibility purposes, active military duty in Southwest Asia during the

Persian Gulf War would include service in one or more of the following areas: Iraq, Kuwait, Saudi Arabia, the

neutral zone (between Iraq and Saudi Arabia), Bahrain, Qatar, the United Arab Emirates, Oman, waters of the

Persian Gulf, Red Sea, Arabia Sea, and Gulfs of Aden and Oman.

53. Persian Gulf War Period of Service. Public Law 102-25 established a Persian Gulf War period of service

which will affect persons serving on active duty as of August 2, 1990, with no ending date established by law.

54. Records Control Schedule (RCS) 10-1. Provides instructions for record retention and disposition.

55. Reports Control Symbol (RCS) 10-0860. Reflects the reporting requirements for VA Form 10-9009A (July

1995), Persian Gulf Registry Code Sheet, Persian Gulf Referral Center Monthly Report, and Bi-monthly Report on

Persian Gulf Uniform Case Assessment Protocol.

56. RCS 10-0875. The reporting requirements for the Bi-monthly Report on Persian Gulf War Veteran Registry

Examinations, under Directive 10-95-053 are rescinded by this manual change.

57. RHP - Reproductive Health Problems.

58. SCID - Structured Clinical Interview for DSM-III.

59. SCUDS - Soviet designed surface to surface missiles.

60. SED - Skin Erythema Dose.

61. SGPT(ALT) - Transaminase Glutamic Pyruvate.

62. SGOT(AST) - Glutamic Oxaloacetic Transaminase.

63. SMA (6/12) - SMA is a Manufacturer’s Trademark for a Chemistry Analyzer.

64. SSN - Social Security Number.

65. T4 - Thyroxine Total Serum.

66. TB - Tuberculosis.

67. TSH -Thyroid Stimulating Hormone.

68. UCAP- Uniform Case Assessment Protocol.

69. UGI- Upper Gastrointestinal.

M-10, Part III September 14, 1995

Chapter 2

Change 1

APPENDIX 2A

2A-4

70. VA - Department of Veterans Affairs.

71. VBC - Veterans Benefits Counselor.

72. VDRL - Venereal Disease Research Laboratory.

73. VHA - Veterans Health Administration.

74. VRC - Veterans’ Registry Coordinator - A non-physician staff member responsible for the administrative

management of the program at each VA facility.

75. VRP - Veterans’ Registry Physician - The VRP is a physician responsible for the clinical management of the

Persian Gulf Program at each VA medical facility.

76. VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet.

77. VA Form 10-9009B - Identification Sticker entitled “Persian Gulf.”

78. VA Form 30-7252 changed to VA Form 7252, Transmittal Form for Use in Shipment of Tabulating Data.

79. WBC - White Blood Cells.

September 14, 1995 M-10, Part III

Chapter 2

Change 1

APPENDIX 2A

2A-5

March 21, 1996 M-10, Part III

Change 2

Chapter 2

APPENDIX 2B

2B-1

PROTOCOL FOR CONDUCTING THE PHYSICAL EXAMINATION

AND ORDERING DIAGNOSTIC STUDIES

1. It is essential that a complete medical history, physical examination and interview be performed and

documented on appropriate forms . The required forms that must be fully completed are: Standard Form (SF) 88,

Report of Medical Examination, Department of Veterans Affairs (VA) Form 10-9009A, Persian Gulf Registry Code

Sheet, and SF 509, Progress Notes (for follow-up). These are to be maintained in the veteran's Consolidated

Health Record (CHR). NOTE: This should be accomplished by or under the direct supervision of the Veterans’

Registry Physician (VRP). Examination data will be recorded in the veteran’s medical record as routinely as done

for any other medical examination. The complete medical history should address the following:

(a) Family history;

(b) Occupational history;

(d) Civilian exposure(s) history to possible toxic agents;

(e) Psychosocial history; and

(f) Review of systems.

2. The person actually performing the physical examination will be identified by name, signature and title (i.e.,

Doctor of Osteopathy, Doctor of Medicine, Physician’s Assistant, etc.). A physician’s countersignature is required

if the examiner is other than a physician. Under normal circumstances, VRP will provide such countersignatures.

3. When a Persian Gulf Registry (PGR) examination is done as part of a compensation and pension examination,

the physical examination will be done by/or under the direct supervision of the VRP.

4. The physician should be aware of the variety of exposures endemic to the Persian Gulf area. These are listed

in Appendix 2C and on VA Form 10-9009A. There has been a wide distribution of major categories of diagnosis

reported by VA VRPs; however, no significant variation in occurrence of major categories of medical problems has

been identified. We are listing below (for informational purposes) some of the health problems and/or diseases

which should be considered:

NOTE: Unfortunately the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM)

coding system does not give sufficient codes to correctly identify all symptoms and diagnoses. A number of

diagnoses that have been reported by Veterans Registry Physicians do not have ICD-9-CM codes for specific

identification in the Veterans Health Administration (VHA) s database. To correct this, three new codes have been

created. They are: Apnea, Sleep (99001), Chronic Fatigue Syndrome (CFS) (99002), and Fibromyalgia (99003).

Make certain these codes are used when completing the Persian Gulf Registry code sheets for patients who have

these diagnoses. As a result of inadequate coding designations, there has been confusion between the symptoms

(complaints) and diagnoses listed on the PGR code sheets. Example one: Arthralgia (diagnostic code 7194) has

been used for the symptom “pain in the joint,” where the symptom code 7819 (other symptoms involving nervous

and musculoskeletal systems) would be more appropriate. Example two: Symptom ICD-9-CM code 78051 has

been designated for insomnia with sleep apnea; however, sleep apnea is more correctly identified as a specific

diagnosis which has the new code 99001.