Social Security Disability Medical Consultations - How to Build Your Case

If the evidence provided by the claimant's own medical				Cooperate during the examination.
sources is inadequate to determine if he or she is				Laboratory Tests - X-rays or other laboratory tests
disabled, additional medical information may be sought				The physician providing the formal interpretation must
by re-contacting the treating source for additional				be identified.
information or clarification, or by arranging for a CE.				If the interpretation is provided on a separate report
The treating source is the preferred source of				form, that report should be attached.
purchased examinations when the treating source is				Findings
qualified, equipped and willing to perform the additional				The physician's examination findings must be
examination or tests for the fee schedule payment				determined on the basis of the physician's
and generally furnishes complete and timely reports.				observations during the examination. (Alternative
Even if only a supplemental test is required, the treating				testing methods should be used to verify the
source is ordinarily the preferred source for this				objectivity of the abnormal findings, when possible; e.g.,
service. SSA's rules provide for using an independent				a seated straight-leg raising test in addition to a supine
source (other than the treating source) for a CE or				straight-leg raising test.) Go to Listing of Impairments -
diagnostic study if: The treating source prefers not to				Adults: Musculoskeletal System 1.00 for more
perform the examination; there are conflicts or				information.
inconsistencies in the file that cannot be resolved by				Respiratory
going back to the treating source; the claimant prefers				In addition to the requirements for a general internal
another source and has a good reason for doing so;				medical examination, the specific information listed
or prior experience indicates that the treating source				below should be stated in a report of an examination in
may not be a productive source. The type of				which the primary complaint is a respiratory disorder.
examination and/or test (s) purchased depends upon				General Examination
the specific additional evidence needed for				The report should note and describe:
adjudication. If an ancillary test (e.g., X-ray, PFS or				The occurrence of cough, labored breathing, use of
EKG) will furnish the additional evidence needed for				accessory muscles of respiration, audible wheezing,
adjudication, the DDS will not request or authorize a				pallor, cyanosis, hoarseness, clubbing of fingers, or the
more comprehensive examination. If the examination				presence of chest wall deformity. Respiratory rate
indicates that additional testing may be warranted, the				should be observed and reported.
provider must contact the DDS for approval before				The diameter of the chest on inspiration and expiration,
performing such testing. Fees for CEs are set by each				distention of neck veins and ankle edema.
State and may vary from State to State. Each State				Whether the expiratory phase of respiration is
agency is responsible for comprehensive oversight				prolonged.
management of its CE program.				Breath sounds.
Selection of a Consultative Examination Source				Diaphragmatic motion.
The DDS purchases consultative examinations only				Presence or absence of adventitious sounds on
from qualified medical sources. The medical source				auscultation of the chest.
may be the individual's own physician or psychologist,				The employment history, when relevant to the disease,
or another source. In the case of a child, the medical				should be reported (e.g., pneumoconiosis or exposure
source may be a pediatrician.				to physical irritants producing respiratory symptoms.)
By "qualified," we mean that the medical source must				Dyspnea
be currently licensed in the State and have the training				Characteristics - Dyspnea should be described with
and experience to perform the type of examination or				respect to:
test we request. Also, the medical source must not be				Dates and mode of onset;
barred from participation in our programs. The medical				Seasonal influence;
source must also have the equipment required to				Influence of infection and precipitating activities;
provide an adequate assessment and record of the				Whether it is associated with palpitation, wheezing,
existence and level of severity of the individual's				chest discomfort, or hyperventilation symptoms.
alleged impairments.				Respiratory Versus Cardiac Dyspnea - Inquiry should
Medical professionals who perform CEs must have a				be made to determine whether the claimant has:
good understanding of SSA's disability programs and				A history of heart disease;
their evidence requirements. The physician or				Experienced paroxysmal nocturnal dyspnea or
psychologist chosen may use support staff to help				orthopnea; and
perform the consultative examination. Any such				Associated peripheral edema, hypertension, past
support staff (e.g., X-ray technician, nurse, etc.) must				myocardial infarction, angina, rheumatic heart disease,
meet appropriate licensing or certification requirements				cardiac murmur, etc.
of the State.				Episodic Disorders - The report should include details
Generally, sources are selected based on appointment				as to:
availability, distance from a claimant's home and ability				Onset and precipitating factors;
to perform specific examinations and tests.				Frequency and intensity;
Consultative Examination Report Content				Duration;
The examination report should include the claimant's				Mode of treatment and response; and
claim number and a physical description of the claimant,				Description of severe respiratory attack.
to help ensure that the person being examined is the				Ancillary Studies
claimant.				Chest X-ray, Spirometry, Diffusing Capacity of the
The detail and format for reporting the results of the				lungs for Carbon Monoxide, and Arterial Blood Gas
medical history, physical examination, laboratory				Studies will be requested in accordance with program
findings, and discussion of conclusions should follow the				criteria for the purpose of establishing the existence
standard reporting principles for a complete medical				and extent of the disease process. Go to Listing of
examination.				Impairments -Adults: Respiratory System 3.00 for
The report should be complete enough to enable an				more information.
independent reviewer to determine the nature, severity				Cardiovascular
and duration of the impairment, and, in adults, the				In addition to the requirements for a general internal
claimant's ability to perform basic work-related				medical examination, the following specific information
functions. The history and physical examination must				should be stated in a report of an examination in which
be provided as a narrative of the findings.				the primary complaint is a cardiovascular disorder.
Conclusions in the report must be consistent with the				General Examination - The report must:
objective clinical findings found on examination and the				Provide a detailed description of the examination of
claimant's symptoms, laboratory studies, and				the heart, including the heart sounds and rhythm and
demonstrated response to treatment and on all				pulses.
available information, including the history. The report,				Describe:
for adults, should include a description, based on the				Any jugular vein distention, including angle of reclining at
provider's own findings, of the individual's ability to do				which distention occurs;
basic work-related activities. It should not include an				Adventitious lung sounds;
opinion as to whether the claimant is disabled under the				Hepatomegaly;
meaning of the law.				Peripheral or pulmonary edema; and
Signature Requirements				Cyanosis.
All CE reports must be personally reviewed and				Describe the impact of the chest discomfort, dyspnea
signed by the provider who actually performed the				or other cardiovascular symptoms on physical
examination. The provider doing the examination or				activities.
testing is solely responsible for the report contents and				Describe any drugs used (currently and in the recent
for the conclusions, explanations or comments				past) for treatment of the cardiovascular disorder and
provided. The source's signature on a report annotated				indicate the dosage and the response to these drugs.
"not proofed" or "dictated but not read" is not				Note participation in a cardiac rehabilitation program
acceptable. A rubber stamp signature or signature				(e.g., progressive physical activity, educational or
entered by another person, such as a nurse or				psychological support).
secretary, is not acceptable.				Congestive Heart Failure - The history must include a
How the DDS Reviews Consultative Examination				discussion of:
Reports				The known factors in the development of the cardiac
The DDS is obligated to review the report of the CE				condition (e.g., myocardial infarction, rheumatic heart
to determine whether the specific information				disease, hypertension, and congenital or other organic
requested has been furnished.				heart disease).
The CE report must:				Recurrent or persistent symptoms such as:
Provide evidence that serves as an adequate basis				Fatigue;
for disability decision making in terms of the impairment				Dyspnea;
it assesses.				Orthopnea; and
Be internally consistent. Are all the diseases,				Anginal discomfort.
impairments and complaints described in the history				Chest Discomfort and Other Symptoms - The report
adequately assessed and reported in the clinical				should describe:
findings?				Chest discomfort of myocardial ischemic origin or
Do the conclusions correlate the medical history, the				other symptom(s) in the claimant's own words with
clinical examination and laboratory tests, and explain all				respect to:
abnormalities?				Presence;
Be consistent with the other information available within				Character;
the specialty of the examination requested.				Location;
Did the report fail to mention an important or relevant				Radiation;
complaint within that specialty that is noted in other				Frequency;
evidence in the file (e.g., blindness in one eye,				Duration;
amputations, pain, alcoholism, depression)?				Usual inciting factors; and
Be adequate as compared to the standards set out in				Relief.
the course of a medical education.				The historical character of the chest discomfort to
Be properly signed.				ascertain whether:
If the report is inadequate or incomplete, the DDS will				There is a predictable stable pattern of occurrence;
contact the provider and ask the provider to furnish				and
the missing information or prepare a revised report.				There is evidence of a recent change in the pattern of
Elements of a Complete Consultative Examination				symptoms;
A complete CE is one that involves all the elements of				Whether therapy has been prescribed and how the
a standard examination in the applicable medical				claimant is responding to the therapy;
specialty. When the report of a complete CE is				Whether the discomfort occurs at rest or awakens
involved, the report should include the following				the claimant from sleep and whether it is related to
elements:				ingestion of food or movement of the upper
The claimant's major or chief complaint(s);				extremities; and
Detailed description, within the area of specialty of the				The usual duration of the symptoms, especially chest
examination, of the history of the major complaint(s);				discomfort, how symptoms are relieved, and the time
Description, and disposition, of pertinent "positive" and				required to obtain relief (e.g., rest or after taking specific
"negative" detailed findings based on the history,				drugs such as nitroglycerin).
examination, and laboratory tests related to the major				Laboratory Tests
complaint(s), and any other abnormalities or lack				Ancillary cardiac testing, such as ECG, Exercise Stress
thereof reported or found during examination or				Testing and Echocardiogram, will be requested in
laboratory testing;				accordance with program criteria for the purpose of
Results of laboratory and other tests (e.g., X-rays)				establishing the existence and extent of the disease
performed in accordance with the requirements				process. Go to Listing of Impairments - Adults:
provided by the DDS.				Cardiovascular System 4.00 for more information.
Diagnosis and prognosis for the claimant's				Neurological
impairment(s);				Historical Source
Statement about what the claimant can still do despite				The DDS will make arrangements to have a
his or her impairment(s), unless the claim is based on				knowledgeable individual accompany the claimant to
statutory blindness. This statement should describe the				the examination, when prior information indicates
opinion of the consulting physician or psychologist				incompetence on the part of the claimant.
about the claimant's ability, despite his or her				The physician should indicate from whom the history
impairment(s), to do work-related activities such as				was obtained and should estimate reliability of history.
sitting, standing, walking, lifting, carrying, handling objects,				History - The history should include a detailed
hearing, speaking, and traveling; and, in cases of mental				description/discussion of:
impairment(s), the opinion of the physician or				Major or chief complaints with:
psychologist about the individual's ability to understand,				Detailed historical description of the disease state; and
to carry out and remember instructions, and to				Current complaints.
respond appropriately to supervision, coworkers, and				The mental or physical functional restrictions with
work pressures in a work setting; and				specific examples.
The consultative physician or psychologist will consider,				Significant illness, injuries, or operations, particularly of
and provide some explanation or comment on, the				the nervous system.
claimant's major complaint(s) and any other				Current and past therapy for the disorder alleged, and
abnormalities found during the history and examination				any abuse or drugs or alcohol.
or reported from the laboratory tests. The history,				The family history with information on pertinent positive
examination, evaluation of laboratory test results, and				abnormalities, particularly hereditary familial conditions.
the conclusions will represent the information provided				Physical Examination
by the physician or psychologist who signs the report.				General - The physical examination should provide a
Report Content by Specific Impairment				statement concerning the claimant's:
Internal Medicine				General appearance;
The detail and format for reporting the results of the				Nutrition;
history, physical examination, laboratory findings, and				Body habitus;
discussion of conclusions should follow the standard				Head size and shape;
reporting principles for a complete internal medical				Any skeletal or other abnormalities such as pigmentary
examination.				or texture changes of the skin or changes in hair
Source of History				distribution; and
The physician should indicate from whom the history				Dominant hand
was obtained and should provide an estimate of the				The gait and station must be described in detail,
reliability of the history.				including ability to:
History of Present Illness				Tandem walk;
The chief complaint(s) alleged as the reason for not				Walk on heels and toes;
working should be discussed in detail, including:				Hop;
Factors which increase the problem or impairment(s);				Dress and undress;
How long the problem has been present;				Get up from a chair;
Factors which may provide relief; and				Get on the examining table; and
The claimant's description of how the impairment(s)				Generally cooperate during the examination.
limits the ability to function.				Notation should be made of the function of the 12
Pertinent descriptive statements by the claimant, such				cranial nerves (if the first cranial nerve is not tested,
as a description of chest pain, should be recorded in				this should be noted). Lower cranial nerve function
the claimant's own words.				should be described in particular detail when dysphagia
The information must be in a narrative, rather than				or dysarthria is a complaint.
"questionnaire" or "check-off" format.				Ocular motility and pupillary size and activity should be
Past History should describe other prior illnesses,				described even when normal. The visual acuity and
injuries, operations, or hospitalizations and give the				visual fields by gross confrontation should be
dates of these events.				estimated, and the basis for the estimate must be
Current Medication should be listed by name of drug				stated.
and dose.				Motor function - Should be quantitated, and the method
Review of Systems should describe and discuss:				of quantitation reported. For example, if a numbering
Other complaints and symptoms the claimant has				system is used, the report must state which number
experienced relative to the specific organ systems,				represents normal strength and which number
and				represents total paralysis.
The pertinent negative findings, which would be				The report must also describe to what degree motor
considered in making a differential diagnosis of the				function is inhibited by spasticity, rigidity, involuntary
current illness or in evaluating the severity of the				movements, or tremor.
impairment.				Muscle bulk should be described, and when there is
Social History should include pertinent findings about				asymmetry, measurements should be reported.
use of tobacco products, alcohol, nonprescription drugs,				The degree of fatigability following rapid, repetitive
etc.				movements should be noted.
Family History should be presented, if pertinent.				All modalities of sensation, including cortical, should be
Signs				tested.
The vital signs should include:				The method of testing should be recorded.
Blood pressure;				When sensory deficit or pain are described in a
Pulse rate;				specific distribution, care should be taken to ascertain
Respiratory rate; and				that the findings are consistent with neuroanatomical
Height and weight without shoes.				fact. Suspected non-physiological observations should
The physical examination must provide a description of				be noted.
the claimant's general appearance and pertinent				Coordination should be tested.
behavior during the examination (e.g., for back				The ability to perform fine and dexterous movements
complaint, how the claimant stood or walked, got up				of the hands should be described.
from a chair, and got on and off the examination table).				In-coordination or tremor at rest or during specific tests
This description must be in narrative, rather than				should be described in detail and quantitated.
"questionnaire" or "check-off" form.				NOTE: Examples should be given describing the
The report should present aspects of the examination				functional loss that occurs because of these events.
dealing with the claimant's major and minor complaints				Reflexes
in particular detail, describing both pertinent negative				Deep tendon reflexes should be described as to
and positive findings.				intensity and symmetry.
Pelvic examinations should not be performed unless				Superficial reflexes should be described when present
specifically authorized.				and noted when absent.
Specific range of motion of a joint should be reported				Any pathological reflexes must be described in detail.
in degrees for joints in which there is a significant				Any impairment of speech or language should be
limitation of motion.				described in detail with a discussion of how much
NOTE: If a joint is found to have no abnormality of				ability the claimant retains and how the physician
range of motion on gross examination, that fact should				determined this. The report should discuss:
be stated rather than reporting the degree of motion.				Aphasia;
Laboratory Tests - The laboratory should provide:				Dysarthria;
Actual values for laboratory tests; and				Stuttering (fluency);
Normal ranges of values in either the medical report or				Involuntary vocalizations;
attached laboratory report.				Whether speech is intelligible.
Electrocardiographic and Spirographic Reports				Mental Status Examination - should be reported and
Tracings must be provided when these tests have				be extensive when mental capacity is in question. The
been performed.				physician should provide:
The reported findings for pulmonary and				Examples of responses in testing orientation, memory,
electrocardiographic studies must meet the				calculation, insight, general understanding, and fund of
requirements of Section 3.00E and 4.00C, respectively,				knowledge; and
of the Listing of Impairments.				A detailed description of mood and behavior during the
Interpretation				examination, and any significant abnormalities. Go to
The interpretation of laboratory tests (e.g.,				Listing of Impairments - Adult: Neurological 11.00 for
electrocardiographic tracings) must take into account				more information.
and be correlated with the history and physical				Mental Disorders
examination findings.				The psychiatric or psychological examination report
Identify the physician providing the formal interpretation				should show not only the claimant's signs, symptoms,
of the laboratory tests, when other than the physician				laboratory findings (psychological test results), and
who is signing the CE report.				diagnosis, but also describe the effect of the emotional
If the interpretation is provided separately, the report				or mental disorder on the claimant's ability to function at
sheet should state the interpreting physician's name				the usual and customary level of adjustment -
and address.				personal, social and occupational.
X-rays				General Observations - Include in the CE report
Joints and other areas to be x-rayed are those that				general observations of:
are specifically requested or those that the physical				How the claimant came to the examination:
examination reveals to be the most involved by				Alone or accompanied;
disease, after appropriate authorization by the DDS.				Distance and mode of transportation; and
Rheumatology				If by automobile, who drove.
In addition to the requirements for a general internal				General appearance:
medical examination, the following specific information				Dress; and
should be stated in a report of an examination in which				Grooming
the primary complaint is a rheumatological disorder.				Attitude and degree of cooperation.
General Observations				Posture and gait.
General observations in the physical examination				General motor behavior, including any involuntary
should relate to common, everyday functions which				movements.
may be observed in the examining physician's office,				Informant
such as:				The psychiatrist or psychologist should identify the
Stance;				person providing the history (usually the claimant) and
Gait;				should provide an estimate of the reliability of the
Ability to:				history.
Dress and undress;				Chief Complaint
Climb upon the examining table;				This usually will consist of the claimant's allegations
Grasp or shake hands; and				concerning any mental and/or physical problems.
Write.				History of Present Illness
Joint Examination				This should include a detailed chronological account of
Joint examination should include specific, detailed				the onset and progression of the claimant's current
notations with respect to the presence or absence of:				mental/emotional condition with special reference to:
Effusion;				Date and circumstances of onset of the condition;
Episodes of infection;				Date the claimant reported that the condition began to
Peri-articular swelling;				interfere with work, and how it interfered;
Tenderness;				Date the claimant reported inability to work because of
Heat;				the condition and the circumstances;
Redness;				Attempts to return to work and the results;
Thickening of the joints;				Outpatient evaluations and treatment for mental
Specific range of motion of the joints and back in				emotional problems including:
degrees; and				Names of treating sources;
Structural deformities.				Dates of treatment;
Specific range of motion of a joint or spine should be				Types of treatment (names and dosages of
reported in degrees for any joint or spine in which				medications, if prescribed); and
there is a significant limitation of motion.				Response to treatment.
If the range of motion is found to be restricted in any				Hospitalizations for mental disorders including:
joint or spine, annotation should be made as to				Names of hospitals;
probable cause (e.g., due to pain and/or influenced by				Dates; and
observable abnormality).				Treatment and response.
Joints/spine to be x-rayed are those that are				Information concerning the claimant's:
specifically requested or those that the physical				Activities of daily living;
examination reveals to be the most involved by				Social functioning;
disease, after appropriate authorization by DDS.				Ability to complete tasks timely and appropriately; and
For individuals alleging myalgias or other muscular				Episodes of decompensation and their resulting
complaints, evaluate the areas of muscle tenderness				effects.
including tender points and trigger points. Go to Listing				Past History should include a longitudinal account of the
of Impairments - Adults: Immune System 14.00 for				claimant's personal life including:
more information.				Relevant educational, medical, social, legal, military,
Orthopedic				marital, and occupational data and any associated
History				problems in adjustment;
The orthopedic examination, including the lumbar and				Details (dates, places, etc.) of any past history of
cervical spine, should describe and discuss (where				outpatient treatment and hospitalizations for mental
appropriate):				emotional problems; and
The major or chief complaint(s) alleged as the reason				History, if any, of substance abuse, and/or treatment in
for not working. The discussion of the complaints must				detoxification and rehabilitation centers.
include:				Mental Status
A detailed historical description of the pertinent past				The individual case facts will determine the specific
history of the disease.				areas of mental status that need to be emphasized
The claimant's statement of current complaint.				during the examination, but generally the report should
Current and past therapy for this disorder, and				include a detailed description of the claimant's:
response to therapy, should be reported.				Appearance, behavior, and speech (if not already
Hospitalizations, surgical operations, and significant				described);
investigative procedures (e.g., myelography, CAT scan,				Thought process (e.g., loosening of associations);
MRI, Bone Scan) should be reported with the dates of				Thought content (e.g., delusions);
the hospitalizations and result of the procedures.				Perceptual abnormalities (e.g., hallucinations);
The symptoms alleged, including a description of:				Mood and affect (e.g., depression, mania);
The character, location, and radiation of pain;				Sensorium and cognition (e.g., orientation, recall,
Mechanical factors which incite and relieve the pain;				memory, concentration, fund of information, and
Prescribed treatment, including name, dose, and				intelligence);
frequency of any medications which are used;				Judgment and insight; and
The claimant's typical daily activities; and				Capability (i.e., is the individual capable of handling
Symptoms of weakness, other motor loss, or any				awarded benefits responsibly?)
sensory abnormalities.				Diagnosis
The use of drugs or alcohol.				American Psychiatric Association standard
Other significant past illnesses, injuries, operations,				nomenclature as set forth in the current "Diagnostic
particularly those involving the musculoskeletal system.				and Statistical Manual of Mental Disorders."
From whom the history was obtained and an estimate				Prognosis
of the reliability of the history.				Prognosis and recommendations for treatment, if
Physical Examination - The physical examination report				indicated; also, recommendations for any other medical
should include a description and discussion (where				evaluation (e.g., neurological, general physical), if
appropriate) of:				indicated.
The claimant's general appearance and nutrition, any				Additional Requirements by Mental Disorder
apparent skeletal or other musculoskeletal				Schizophrenic, Delusional (Paranoid) Schizo-Affective,
abnormalities.				and other Psychotic Disorders - The report should
The orthopedic and neurological findings. These should				reflect:
include a description of:				Periods of residence in structured settings such as
Muscle spasms, limitation of movement of the spine				half-way houses and group homes;
given quantitatively in degrees from the vertical position				Frequency and duration of episodes of illness and
when there is significant limitation in motion, straight leg				periods of remission; and
raising given quantitatively in degrees from the supine				Side effects of medications.
position and from the sitting position, motor and				Organic Mental Disorders - The report should reflect:
sensory abnormalities, and deep tendon reflexes. Deep				The source of the disorder, if known, the prognosis;
tendon reflexes should be described as to intensity				and
and symmetry.				Whether there is an acute or chronic process;
If there is no abnormality of range of motion of any				Whether stable or progressive; and
affected joint on gross examination, that fact, rather				Changes at various points in time.
than the actual degree of motion, may be reported.				The results of any psychological or neuropsychological
Motor function quantitative. The method of quantitation				testing that could serve to further document an
must be reported. The most widely used method				organic process and its severity.
involves recording from 0 to 5 as a fraction with the				Information regarding the results of any neurological
numerator representing the claimant's performance				evaluations.
and the denominator representing a normal				Information about any neurological testing (e.g., EEG,
performance (e.g., 3/5).				CT scan) that may have been performed and the
To what degree motor function is inhibited by				results, if available.
spasticity, rigidity or pain.				In Mental Retardation cases, the report should reflect:
The specific distribution of sensory deficit or pain.				Current documentation of IQ by a standardized,
Muscle bulk. When there is asymmetry, specific				well-recognized measure. Acceptable instruments will
measurement must be reported.				have a representative normative sample, a mean of
Atrophy must be reported in terms of circumferential				approximately 100 and standard deviation of
measurements of both thighs and lower legs (or upper				approximately 15 in the general population, and cover a
or lower arms) at a stated point above and below the				broad range of cognitive and perceptual-motor
knee or elbow given in inches or centimeters.				functions (e.g., the Wechsler scales);
A specific description of atrophy of hand muscles may				Verbal IQ, performance IQ, and full scale IQ scores,
be given without measurements of atrophy but should				together with the individual subtest scores;
include measurements of grip strength.				Interpretation of the scores and assessment of the
Gait and station, including the claimant's ability to:				validity of the obtained scores, indicating any factors
Tandem walk;				that may have influenced the results such as the
Walk on heels and toes;				claimant's attitude and degree of cooperation, the
Hop;				presence of visual, hearing or other physical problems,
Bend;				and recent prior exposure to the same or similar test;
Squat;				and
Arise from a squatting position;				Consistency of the obtained test results with the
Dress and undress;				claimant's education, vocational background, and social
Get up from a chair;				adjustment, especially in the area of personal
Get on the examining table; and				self-sufficiency.

WorkAbility

Social Security Disability Medical Consultations - How to Build Your Case