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