VA Diagnostic Code 8045Residuals of traumatic brain injury (TBI)
Rated under § 4.124a. No rating levels have been extracted for this code yet — use the official source.
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Summary
There are three main areas of dysfunction that may result from TBI: cognitive, emotional/behavioral, and physical. Cognitive impairment and subjective symptoms are evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified," which contains 10 facets with impairment levels from 0 to 3 plus a 5th level labeled "total." Assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. Emotional/behavioral dysfunction is evaluated under § 4.130 when there is a diagnosis of a mental disorder; otherwise under the table. Physical (including neurological) dysfunction is evaluated under an appropriate diagnostic code. Separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code (such as migraine headache or Meniere's disease), and combine under § 4.25.
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Notes on this code
These notes are part of the regulation. They change how the levels above are applied.
- Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition.
- Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation.
- Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet.
- Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045.
- Note (5): A veteran whose residuals of TBI are rated under a version of § 4.124a, diagnostic code 8045, in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable.
Residuals of Traumatic Brain Injury (TBI)
VA Diagnostic Code 8045 · 38 CFR § 4.124a · Neurological Conditions and Convulsive Disorders
Understanding This Condition
A traumatic brain injury can leave lasting effects long after the initial injury. Under VA Diagnostic Code 8045, the residuals of TBI are grouped into three main areas of dysfunction:
- Cognitive — how you think, remember, concentrate, and process information
- Emotional/behavioral — how the injury affects mood and behavior
- Physical — including neurological effects on the body
Because a single brain injury can produce very different symptoms from one person to the next, the VA evaluates each area using the framework that best fits how the injury actually affects you.
A note on "mild," "moderate," and "severe." You may see these terms in your medical records. Under Note (4), they describe how the injury was classified at or near the time it happened — not your current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045.
How the Rating Levels Work
Cognitive impairment and other subjective symptoms are evaluated under a table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." This table contains 10 facets, each scored on impairment levels from 0 to 3, plus a fifth level labeled "total."
The overall percentage is assigned as follows:
| Highest Facet Level | Rating Assigned |
|---|---|
| Any facet evaluated as "total" | 100% |
| Level 3 (and no facet is "total") | 70% |
| Level 2 | 40% |
| Level 1 | 10% |
| Level 0 | 0% |
In other words, if no facet reaches "total," your overall evaluation is based on the highest single facet score.
How Different Areas Are Evaluated
Emotional/behavioral dysfunction is evaluated under § 4.130 (the mental disorders criteria) when there is a diagnosis of a mental disorder. If there is no such diagnosis, it is evaluated under the TBI table instead.
Physical (including neurological) dysfunction is evaluated under whichever diagnostic code is appropriate for that specific residual.
Separately diagnosable residuals — such as migraine headaches or Meniere's disease — that can be evaluated under another diagnostic code are rated separately, and the results are combined under § 4.25.
What the VA Looks For
- Which facets are affected and how severely. The 10 facets in the TBI table each carry an impairment level, and the highest level generally drives the overall rating (unless a facet reaches "total," which supports a 100% evaluation).
- Whether symptoms overlap with another condition. Under Note (1), the VA does not assign more than one evaluation based on the same manifestations. If symptoms of two or more conditions cannot be clearly separated, a single evaluation is assigned under whichever criteria better capture your overall impaired functioning. If the manifestations are clearly separable, each condition can be evaluated separately.
- The impact on daily functioning. Note (3) distinguishes between:
- Activities of daily living (ADLs) — basic self-care such as bathing, dressing, eating, getting in or out of bed or a chair, and using the toilet.
- Instrumental activities of daily living (IADLs) — activities needed for independent living beyond self-care, such as preparing meals, housework and chores, shopping, traveling, doing laundry, managing your own medications, and using a telephone.
- Examples are just examples. Under Note (2), the symptoms listed at each evaluation level in the table are only illustrations. They do not all have to be present in order for a particular evaluation to be assigned.
A Note on Older Ratings (Before October 23, 2008)
Under Note (5), a veteran whose TBI residuals were rated under a version of § 4.124a, Diagnostic Code 8045, that was in effect before October 23, 2008 may request a review under the current Diagnostic Code 8045 — regardless of whether the disability has worsened since the last review. The VA will review the rating to determine whether a higher evaluation may be warranted.
A request under this note is treated as a claim for an increased rating for the purpose of setting an effective date. However, in no case will the award be effective before October 23, 2008. For determining the effective date, the VA will apply 38 CFR 3.114, if applicable.
These criteria are a rendering of § 4.124a, diagnostic code 8045. The official version is the one that governs your rating.
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