How to Build a Social Security Disability Case

If the evidence provided by the claimant’s				laboratory tests
own medical sources is inadequate to determine if				The physician providing the formal interpretation
he or she is disabled, additional medical information				must be identified.
may be sought by re-contacting the treating				If the interpretation is provided on a separate
source for additional information or clarification, or				report form, that report should be attached.
by arranging for a CE. The treating source is the				Findings
preferred source of purchased examinations				The physician’s examination findings must be
when the treating source is qualified, equipped and				determined on the basis of the physician’s
willing to perform the additional examination or				observations during the examination. (Alternative
tests for the fee schedule payment and generally				testing methods should be used to verify the
furnishes complete and timely reports. Even if				objectivity of the abnormal findings, when
only a supplemental test is required, the treating				possible; e.g., a seated straight-leg raising test in
source is ordinarily the preferred source for this				addition to a supine straight-leg raising test.) Go to
service. SSA’s rules provide for using an				Listing of Impairments - Adults: Musculoskeletal
independent source (other than the treating				System 1.00 for more information.
source) for a CE or diagnostic study if: The				Respiratory
treating source prefers not to perform the				In addition to the requirements for a general
examination; there are conflicts or inconsistencies				internal medical examination, the specific
in the file that cannot be resolved by going back				information listed below should be stated in a
to the treating source; the claimant prefers				report of an examination in which the primary
another source and has a good reason for doing				complaint is a respiratory disorder.
so; or prior experience indicates that the treating				General Examination
source may not be a productive source. The				The report should note and describe:
type of examination and/or test (s) purchased
depends upon the specific additional evidence				The occurrence of cough, labored breathing, use
needed for adjudication. If an ancillary test (e.g.,				of accessory muscles of respiration, audible
X-ray, PFS or EKG) will furnish the additional				wheezing, pallor, cyanosis, hoarseness, clubbing of
evidence needed for adjudication, the DDS will not				fingers, or the presence of chest wall deformity.
request or authorize a more comprehensive				Respiratory rate should be observed and
examination. If the examination indicates that				reported.
additional testing may be warranted, the provider				The diameter of the chest on inspiration and
must contact the DDS for approval before				expiration, distention of neck veins and ankle
performing such testing.				edema.
Fees for CEs are set by each State and may				Whether the expiratory phase of respiration is
vary from State to State. Each State agency is				prolonged.
responsible for comprehensive oversight				Breath sounds.
management of its CE program.				Diaphragmatic motion.
Selection of a Consultative Examination Source				Presence or absence of adventitious sounds on
The DDS purchases consultative examinations				auscultation of the chest.
only from qualified medical sources. The medical
source may be the individual’s own physician				The employment history, when relevant to the
or psychologist, or another source. In the case of				disease, should be reported (e.g., pneumoconiosis
a child, the medical source may be a pediatrician.				or exposure to physical irritants producing
By “qualified,” we mean that the medical				respiratory symptoms.)
source must be currently licensed in the State				Dyspnea
and have the training and experience to perform				Characteristics — Dyspnea should be described
the type of examination or test we request. Also,				with respect to:
the medical source must not be barred from
participation in our programs. The medical source				Dates and mode of onset;
must also have the equipment required to provide				Seasonal influence;
an adequate assessment and record of the				Influence of infection and precipitating activities;
existence and level of severity of the				Whether it is associated with palpitation, wheezing,
individual’s alleged impairments.				chest discomfort, or hyperventilation symptoms.
Medical professionals who perform CEs must have
a good understanding of SSA’s disability				Respiratory Versus Cardiac Dyspnea — Inquiry
programs and their evidence requirements. The				should be made to determine whether the
physician or psychologist chosen may use support				claimant has:
staff to help perform the consultative
examination. Any such support staff (e.g., X-ray				A history of heart disease;
technician, nurse, etc.) must meet appropriate				Experienced paroxysmal nocturnal dyspnea or
licensing or certification requirements of the State.				orthopnea; and
Generally, sources are selected based on				Associated peripheral edema, hypertension, past
appointment availability, distance from a				myocardial infarction, angina, rheumatic heart
claimant’s home and ability to perform				disease, cardiac murmur, etc.
specific examinations and tests.
Consultative Examination Report Content				Episodic Disorders — The report should include
The examination report should include the				details as to:
claimant’s claim number and a physical
description of the claimant, to help ensure that				Onset and precipitating factors;
the person being examined is the claimant.				Frequency and intensity;
The detail and format for reporting the results of				Duration;
the medical history, physical examination,				Mode of treatment and response; and
laboratory findings, and discussion of conclusions				Description of severe respiratory attack.
should follow the standard reporting principles for
a complete medical examination.				Ancillary Studies
The report should be complete enough to enable				Chest X-ray, Spirometry, Diffusing Capacity of
an independent reviewer to determine the nature,				the lungs for Carbon Monoxide, and Arterial Blood
severity and duration of the impairment, and, in				Gas Studies will be requested in accordance with
adults, the claimant’s ability to perform basic				program criteria for the purpose of establishing
work-related functions. The history and physical				the existence and extent of the disease process.
examination must be provided as a narrative of				Go to Listing of Impairments -Adults: Respiratory
the findings.				System 3.00 for more information.
Conclusions in the report must be consistent with				Cardiovascular
the objective clinical findings found on examination				In addition to the requirements for a general
and the claimant’s symptoms, laboratory				internal medical examination, the following specific
studies, and demonstrated response to treatment				information should be stated in a report of an
and on all available information, including the				examination in which the primary complaint is a
history. The report, for adults, should include a				cardiovascular disorder.
description, based on the provider’s own				General Examination — The report must:
findings, of the individual’s ability to do basic
work-related activities. It should not include an				Provide a detailed description of the examination
opinion as to whether the claimant is disabled				of the heart, including the heart sounds and
under the meaning of the law.				rhythm and pulses.
Signature Requirements
All CE reports must be personally reviewed and				Describe:
signed by the provider who actually performed
the examination. The provider doing the				Any jugular vein distention, including angle of
examination or testing is solely responsible for the				reclining at which distention occurs;
report contents and for the conclusions,				Adventitious lung sounds;
explanations or comments provided. The				Hepatomegaly;
source’s signature on a report annotated				Peripheral or pulmonary edema; and
“not proofed” or “dictated but not				Cyanosis.
read” is not acceptable. A rubber stamp
signature or signature entered by another person,				Describe the impact of the chest discomfort,
such as a nurse or secretary, is not acceptable.				dyspnea or other cardiovascular symptoms on
How the DDS Reviews Consultative Examination				physical activities.
Reports				Describe any drugs used (currently and in the
The DDS is obligated to review the report of the				recent past) for treatment of the cardiovascular
CE to determine whether the specific information				disorder and indicate the dosage and the response
requested has been furnished.				to these drugs.
The CE report must:				Note participation in a cardiac rehabilitation
				program (e.g., progressive physical activity,
Provide evidence that serves as an adequate				educational or psychological support).
basis for disability decision making in terms of the				Congestive Heart Failure — The history must
impairment it assesses.				include a discussion of:
				The known factors in the development of the
Be internally consistent. Are all the diseases,				cardiac condition (e.g., myocardial infarction,
impairments and complaints described in the				rheumatic heart disease, hypertension, and
history adequately assessed and reported in the				congenital or other organic heart disease).
clinical findings?				Recurrent or persistent symptoms such as:

Do the conclusions correlate the medical history,				Fatigue;
the clinical examination and laboratory tests, and				Dyspnea;
explain all abnormalities?				Orthopnea; and
				Anginal discomfort.
Be consistent with the other information available
within the specialty of the examination requested.				Chest Discomfort and Other Symptoms —
				The report should describe:
Did the report fail to mention an important or
relevant complaint within that specialty that is				Chest discomfort of myocardial ischemic origin or
noted in other evidence in the file (e.g., blindness in				other symptom(s) in the claimant’s own
one eye, amputations, pain, alcoholism,				words with respect to:
depression)?
				Presence;
Be adequate as compared to the standards set				Character;
out in the course of a medical education.				Location;
				Radiation;
Be properly signed.				Frequency;
				Duration;
If the report is inadequate or incomplete, the DDS				Usual inciting factors; and
will contact the provider and ask the provider to				Relief.
furnish the missing information or prepare a
revised report.				The historical character of the chest discomfort
Elements of a Complete Consultative Examination				to ascertain whether:
A complete CE is one that involves all the
elements of a standard examination in the				There is a predictable stable pattern of
applicable medical specialty. When the report of a				occurrence; and
complete CE is involved, the report should include				There is evidence of a recent change in the
the following elements:				pattern of symptoms;
The claimant’s major or chief complaint(s);				Whether therapy has been prescribed and how
				the claimant is responding to the therapy;
Detailed description, within the area of specialty of				Whether the discomfort occurs at rest or
the examination, of the history of the major				awakens the claimant from sleep and whether it
complaint(s);				is related to ingestion of food or movement of
Description, and disposition, of pertinent				the upper extremities; and
“positive” and “negative” detailed				The usual duration of the symptoms, especially
findings based on the history, examination, and				chest discomfort, how symptoms are relieved,
laboratory tests related to the major complaint(s),				and the time required to obtain relief (e.g., rest or
and any other abnormalities or lack thereof				after taking specific drugs such as nitroglycerin).
reported or found during examination or
laboratory testing;				Laboratory Tests
Results of laboratory and other tests (e.g.,				Ancillary cardiac testing, such as ECG, Exercise
X-rays) performed in accordance with the				Stress Testing and Echocardiogram, will be
requirements provided by the DDS.				requested in accordance with program criteria for
Diagnosis and prognosis for the claimant’s				the purpose of establishing the existence and
impairment(s);				extent of the disease process. Go to Listing of
Statement about what the claimant can still do				Impairments - Adults: Cardiovascular System 4.00
despite his or her impairment(s), unless the claim				for more information.
is based on statutory blindness. This statement				Neurological
should describe the opinion of the consulting				Historical Source
physician or psychologist about the claimant’s				The DDS will make arrangements to have a
ability, despite his or her impairment(s), to do				knowledgeable individual accompany the claimant
work-related activities such as sitting, standing,				to the examination, when prior information
walking, lifting, carrying, handling objects, hearing,				indicates incompetence on the part of the
speaking, and traveling; and, in cases of mental				claimant.
impairment(s), the opinion of the physician or				The physician should indicate from whom the
psychologist about the individual’s ability to				history was obtained and should estimate reliability
understand, to carry out and remember				of history.
instructions, and to respond appropriately to				History — The history should include a detailed
supervision, coworkers, and work pressures in a				description/discussion of:
work setting; and
The consultative physician or psychologist will				Major or chief complaints with:
consider, and provide some explanation or				Detailed historical description of the disease state;
comment on, the claimant’s major				and
complaint(s) and any other abnormalities found				Current complaints.
during the history and examination or reported
from the laboratory tests. The history,				The mental or physical functional restrictions with
examination, evaluation of laboratory test results,				specific examples.
and the conclusions will represent the information				Significant illness, injuries, or operations, particularly
provided by the physician or psychologist who				of the nervous system.
signs the report.				Current and past therapy for the disorder alleged,
				and any abuse or drugs or alcohol.
Report Content by Specific Impairment				The family history with information on pertinent
Internal Medicine				positive abnormalities, particularly hereditary familial
The detail and format for reporting the results of				conditions.
the history, physical examination, laboratory				Physical Examination
findings, and discussion of conclusions should follow				General — The physical examination should
the standard reporting principles for a complete				provide a statement concerning the
internal medical examination.				claimant’s:
Source of History
The physician should indicate from whom the				General appearance;
history was obtained and should provide an				Nutrition;
estimate of the reliability of the history.				Body habitus;
History of Present Illness				Head size and shape;
The chief complaint(s) alleged as the reason for				Any skeletal or other abnormalities such as
not working should be discussed in detail, including:				pigmentary or texture changes of the skin or
				changes in hair distribution; and
Factors which increase the problem or				Dominant hand
impairment(s);				The gait and station must be described in detail,
How long the problem has been present;				including ability to:
Factors which may provide relief; and				Tandem walk;
The claimant’s description of how the				Walk on heels and toes;
impairment(s) limits the ability to function.				Hop;
				Dress and undress;
Pertinent descriptive statements by the claimant,				Get up from a chair;
such as a description of chest pain, should be				Get on the examining table; and
recorded in the claimant’s own words.				Generally cooperate during the examination.
The information must be in a narrative, rather
than “questionnaire” or				Notation should be made of the function of the 12
“check-off” format.				cranial nerves (if the first cranial nerve is not
Past History should describe other prior illnesses,				tested, this should be noted). Lower cranial nerve
injuries, operations, or hospitalizations and give the				function should be described in particular detail
dates of these events.				when dysphagia or dysarthria is a complaint.
Current Medication should be listed by name of				Ocular motility and pupillary size and activity should
drug and dose.				be described even when normal. The visual acuity
Review of Systems should describe and discuss:				and visual fields by gross confrontation should be
				estimated, and the basis for the estimate must
Other complaints and symptoms the claimant has				be stated.
experienced relative to the specific organ				Motor function — Should be quantitated, and
systems, and				the method of quantitation reported. For example,
The pertinent negative findings, which would be				if a numbering system is used, the report must
considered in making a differential diagnosis of the				state which number represents normal strength
current illness or in evaluating the severity of the				and which number represents total paralysis.
impairment.				The report must also describe to what degree
Social History should include pertinent findings				motor function is inhibited by spasticity, rigidity,
about use of tobacco products, alcohol,				involuntary movements, or tremor.
nonprescription drugs, etc.				Muscle bulk should be described, and when there
				is asymmetry, measurements should be reported.
Family History should be presented, if pertinent.				The degree of fatigability following rapid, repetitive
Signs				movements should be noted.
The vital signs should include:				All modalities of sensation, including cortical, should
				be tested.
Blood pressure;				The method of testing should be recorded.
Pulse rate;				When sensory deficit or pain are described in a
Respiratory rate; and				specific distribution, care should be taken to
Height and weight without shoes.				ascertain that the findings are consistent with
				neuroanatomical fact. Suspected non-physiological
The physical examination must provide a				observations should be noted.
description of the claimant’s general				Coordination should be tested.
appearance and pertinent behavior during the				The ability to perform fine and dexterous
examination (e.g., for back complaint, how the				movements of the hands should be described.
claimant stood or walked, got up from a chair,				In-coordination or tremor at rest or during specific
and got on and off the examination table).				tests should be described in detail and quantitated.
This description must be in narrative, rather than				NOTE: Examples should be given describing the
“questionnaire” or “check-off”				functional loss that occurs because of these
form.				events.
The report should present aspects of the				Reflexes
examination dealing with the claimant’s major				Deep tendon reflexes should be described as to
and minor complaints in particular detail, describing				intensity and symmetry.
both pertinent negative and positive findings.				Superficial reflexes should be described when
Pelvic examinations should not be performed				present and noted when absent.
unless specifically authorized.				Any pathological reflexes must be described in
Specific range of motion of a joint should be				detail.
reported in degrees for joints in which there is a				Any impairment of speech or language should be
significant limitation of motion.				described in detail with a discussion of how much
NOTE: If a joint is found to have no abnormality				ability the claimant retains and how the physician
of range of motion on gross examination, that				determined this. The report should discuss:
fact should be stated rather than reporting the
degree of motion.				Aphasia;
Laboratory Tests — The laboratory should				Dysarthria;
provide:				Stuttering (fluency);
				Involuntary vocalizations;
Actual values for laboratory tests; and				Whether speech is intelligible.
Normal ranges of values in either the medical
report or attached laboratory report.				Mental Status Examination — should be
Electrocardiographic and Spirographic Reports				reported and be extensive when mental capacity
Tracings must be provided when these tests				is in question. The physician should provide:
have been performed.
				Examples of responses in testing orientation,
The reported findings for pulmonary and				memory, calculation, insight, general understanding,
electrocardiographic studies must meet the				and fund of knowledge; and
requirements of Section 3.00E and 4.00C,				A detailed description of mood and behavior
respectively, of the Listing of Impairments.				during the examination, and any significant
Interpretation				abnormalities. Go to Listing of Impairments - Adult:
The interpretation of laboratory tests (e.g.,				Neurological 11.00 for more information.
electrocardiographic tracings) must take into
account and be correlated with the history and				Mental Disorders
physical examination findings.				The psychiatric or psychological examination
Identify the physician providing the formal				report should show not only the claimant’s
interpretation of the laboratory tests, when other				signs, symptoms, laboratory findings (psychological
than the physician who is signing the CE report.				test results), and diagnosis, but also describe the
If the interpretation is provided separately, the				effect of the emotional or mental disorder on the
report sheet should state the interpreting				claimant’s ability to function at the usual and
physician’s name and address.				customary level of adjustment — personal,
X-rays				social and occupational.
Joints and other areas to be x-rayed are those				General Observations — Include in the CE
that are specifically requested or those that the				report general observations of:
physical examination reveals to be the most
involved by disease, after appropriate				How the claimant came to the examination:
authorization by the DDS.				Alone or accompanied;
Rheumatology				Distance and mode of transportation; and
In addition to the requirements for a general				If by automobile, who drove.
internal medical examination, the following specific				General appearance:
information should be stated in a report of an				Dress; and
examination in which the primary complaint is a				Grooming
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				movements.
which may be observed in the examining
physician’s office, such as:				Informant
				The psychiatrist or psychologist should identify the
Stance;				person providing the history (usually the claimant)
Gait;				and should provide an estimate of the reliability of
Ability to:				the history.
Dress and undress;				Chief Complaint
Climb upon the examining table;				This usually will consist of the claimant’s
Grasp or shake hands; and				allegations concerning any mental and/or physical
Write.				problems.
				History of Present Illness
Joint Examination				This should include a detailed chronological account
Joint examination should include specific, detailed				of the onset and progression of the
notations with respect to the presence or				claimant’s current mental/emotional condition
absence of:				with special reference to:

Effusion;				Date and circumstances of onset of the condition;
Episodes of infection;				Date the claimant reported that the condition
Periarticular swelling;				began to interfere with work, and how it
Tenderness;				interfered;
Heat;				Date the claimant reported inability to work
Redness;				because of the condition and the circumstances;
Thickening of the joints;				Attempts to return to work and the results;
Specific range of motion of the joints and back in				Outpatient evaluations and treatment for mental
degrees; and				emotional problems including:
Structural deformities.				Names of treating sources;
				Dates of treatment;
Specific range of motion of a joint or spine should				Types of treatment (names and dosages of
be reported in degrees for any joint or spine in				medications, if prescribed); and
which there is a significant limitation of motion.				Response to treatment.
If the range of motion is found to be restricted in
any joint or spine, annotation should be made as				Hospitalizations for mental disorders including:
to probable cause (e.g., due to pain and/or
influenced by observable abnormality).				Names of hospitals;
Joints/spine to be x-rayed are those that are				Dates; and
specifically requested or those that the physical				Treatment and response.
examination reveals to be the most involved by				Information concerning the claimant’s:
disease, after appropriate authorization by DDS.				Activities of daily living;
For individuals alleging myalgias or other muscular				Social functioning;
complaints, evaluate the areas of muscle				Ability to complete tasks timely and appropriately;
tenderness including tender points and trigger				and
points. Go to Listing of Impairments - Adults:				Episodes of decompensation and their resulting
Immune System 14.00 for more information.				effects.
Orthopedic
History				Past History should include a longitudinal account of
The orthopedic examination, including the lumbar				the claimant’s personal life including:
and cervical spine, should describe and discuss
(where appropriate):				Relevant educational, medical, social, legal, military,
				marital, and occupational data and any associated
The major or chief complaint(s) alleged as the				problems in adjustment;
reason for not working. The discussion of the				Details (dates, places, etc.) of any past history of
complaints must include:				outpatient treatment and hospitalizations for
A detailed historical description of the pertinent				mental/emotional problems; and
past history of the disease.				History, if any, of substance abuse, and/or
The claimant’s statement of current				treatment in detoxification and rehabilitation
complaint.				centers.

Current and past therapy for this disorder, and				Mental Status
response to therapy, should be reported.				The individual case facts will determine the specific
Hospitalizations, surgical operations, and significant				areas of mental status that need to be
investigative procedures (e.g., myelography, CAT				emphasized during the examination, but generally
scan, MRI, Bone Scan) should be reported with				the report should include a detailed description of
the dates of the hospitalizations and result of the				the claimant’s:
procedures.
The symptoms alleged, including a description of:				Appearance, behavior, and speech (if not already
				described);
The character, location, and radiation of pain;				Thought process (e.g., loosening of associations);
Mechanical factors which incite and relieve the				Thought content (e.g., delusions);
pain;				Perceptual abnormalities (e.g., hallucinations);
Prescribed treatment, including name, dose, and				Mood and affect (e.g., depression, mania);
frequency of any medications which are used;				Sensorium and cognition (e.g., orientation, recall,
The claimant’s typical daily activities; and				memory, concentration, fund of information, and
Symptoms of weakness, other motor loss, or				intelligence);
any sensory abnormalities.				Judgment and insight; and
				Capability (i.e., is the individual capable of handling
The use of drugs or alcohol.				awarded benefits responsibly?)
Other significant past illnesses, injuries, operations,
particularly those involving the musculoskeletal				Diagnosis
system.				American Psychiatric Association standard
From whom the history was obtained and an				nomenclature as set forth in the current
estimate of the reliability of the history.				“Diagnostic and Statistical Manual of Mental
Physical Examination — The physical				Disorders.”
examination report should include a description and				Prognosis
discussion (where appropriate) of:				Prognosis and recommendations for treatment, if
				indicated; also, recommendations for any other
The claimant’s general appearance and				medical evaluation (e.g., neurological, general
nutrition, any apparent skeletal or other				physical), if indicated.
musculoskeletal abnormalities.				Additional Requirements by Mental Disorder
				Schizophrenic, Delusional (Paranoid)
The orthopedic and neurological findings. These				Schizo-Affective, and other Psychotic Disorders
should include a description of:				— The report should reflect:

Muscle spasms, limitation of movement of the				Periods of residence in structured settings such as
spine given quantitatively in degrees from the				half-way houses and group homes;
vertical position when there is significant limitation				Frequency and duration of episodes of illness and
in motion, straight leg raising given quantitatively in				periods of remission; and
degrees from the supine position and from the				Side effects of medications.
sitting position, motor and sensory abnormalities,				Organic Mental Disorders — The report should
and deep tendon reflexes. Deep tendon reflexes				reflect:
should be described as to intensity and symmetry.				The source of the disorder, if known, the
				prognosis; and
If there is no abnormality of range of motion of				Whether there is an acute or chronic process;
any affected joint on gross examination, that				Whether stable or progressive; and
fact, rather than the actual degree of motion,				Changes at various points in time.
may be reported.
Motor function quantitated. The method of				The results of any psychological or
quantitation must be reported. The most widely				neuropsychological testing that could serve to
used method involves recording from 0 to 5 as a				further document an organic process and its
fraction with the numerator representing the				severity.
claimant’s performance and the denominator				Information regarding the results of any
representing a normal performance (e.g., 3/5).				neurological evaluations.
To what degree motor function is inhibited by				Information about any neurological testing (e.g.,
spasticity, rigidity or pain.				EEG, CT scan) that may have been performed
The specific distribution of sensory deficit or pain.				and the results, if available.
Muscle bulk. When there is asymmetry, specific				In Mental Retardation cases, the report should
measurement must be reported.				reflect:
Atrophy must be reported in terms of
circumferential measurements of both thighs and				Current documentation of IQ by a standardized,
lower legs (or upper or lower arms) at a stated				well-recognized measure. Acceptable instruments
point above and below the knee or elbow given in				will have a representative normative sample, a
inches or centimeters.				mean of approximately 100 and standard
A specific description of atrophy of hand muscles				deviation of approximately 15 in the general
may be given without measurements of atrophy				population, and cover a broad range of cognitive
but should include measurements of grip strength.				and perceptual-motor functions (e.g., the Wechsler
Gait and station, including the claimant’s ability				scales);
to:				Verbal IQ, performance IQ, and full scale IQ
				scores, together with the individual subtest
Tandem walk;				scores;
Walk on heels and toes;				Interpretation of the scores and assessment of
Hop;				the validity of the obtained scores, indicating any
Bend;				factors that may have influenced the results such
Squat;				as the claimant’s attitude and degree of
Arise from a squatting position;				cooperation, the presence of visual, hearing or
Dress and undress;				other physical problems, and recent prior
Get up from a chair;				exposure to the same or similar test; and
Get on the examining table; and				Consistency of the obtained test results with the
Cooperate during the examination.				claimant’s education, vocational background,
				and social adjustment, especially in the area of
Laboratory Tests — X-rays or other				personal self-sufficiency.

Focus Retina

How to Build a Social Security Disability Case