Social Security Disability Determinations and Consultative Exams
When you apply for disability benefits with the Social Security Administration, you may be advised by the state Disability Determinations Section (DDSs) that a "consultative examination" is required. The DDSs are state agencies, funded by the federal government, that review a disability claimant's medical evidence and determine whether the claimant is disabled.
Generally, the DDSs look to the claimant's medical records first for evidence regarding their disability. However, sometimes the evidence is insufficient or unavailable, so a consultative exam is ordered. A consultative exam is a physical or mental examination or test purchased on behalf of a disability claimant by the Social Security Administration in order to make a disability determination.
When Is a Consultative Exam Necessary?
Some examples of when a consultative exam may be necessary are:
1. The additional evidence needed is not contained in the claimant's existing medical records.
2. The evidence that may have been available from a claimant's doctors can't be obtained, for reasons that are beyond the claimant's control, such as the death of or noncooperation by a medical provider.
3. There is an inconsistency in the claimant's medical records.
4. Highly technical or specialized medical evidence is needed.
5. There is an indication of a change in the claimant's condition that is likely to affect the claimant's ability to work, or if the claimant is a child, will affect the child's functioning.
Federal regulations indicate that the preferred source for the consultative exam is the claimant's treating doctor, but the DDS is authorized to order the exam with an independent doctor.
Requirements for the Consulting Doctor
By law, there are specific requirements that consulting doctors must follow:
Consulting doctors are required by law to spend a minimum amount of time evaluating a claimant's condition. The amount of time required depends on the nature of the exam. For example, the following types of exams have the following time requirements:
- General medical examination - at least 30 minutes
- Musculoskeletal or neurological examination - at least 20 minutes
- Psychiatric examination - at least 40 minutes
- Psychological examination - at least 60 minutes (though more may be required depending on the types of psychological tests needed)
- All other examinations - at least 30 minutes, or in accordance with accepted medical practices
The consulting doctor's report must meet accepted professional standards and practices for a complete and competent examination. Although the information contained in the report will vary depending on the type of examination, it must contain sufficient information to allow the DDS to determine the nature, severity, and duration of the claimed impairment, and the claimant's ability to perform basic work functions (for adults), or functioning (for children). Consulting doctors must include what the claimant states are his or her symptoms, the objective medical facts, and the consulting doctor's observations and opinions.
To constitute a complete consultative exam, the consulting doctor must record:
- The claim number;
- A physical description of the claimant;
- The claimant's major complaint;
- A detailed history;
- A description of the relevant positive and negative detailed findings based on the complaint's history, exam and lab tests;
- The results of lab tests;
- A diagnosis and prognosis for the impairment;
- A statement regarding what work-related activities the claimant can do despite the impairment; and
- An explanation or comment on the claimant's major complaint found during the history and exam.
Importantly, the consulting doctor should not opine as to whether the claimant is "disabled"under the meaning of the law.
Review and Signature
The consulting doctor must personally review and sign the report. "Rubber stamping" reports is not allowed, nor is a signature with the annotation "dictated but not read."
Before and After the Consultative Exam
Before going to the exam, claimants should be prepared to provide a clear statement of their symptoms, history (including medicines taken and doctors seen), and the primary reasons that they can't work due to their condition. After the exam has been completed, claimants should make a written record that reflects how many minutes the doctor spoke with you, what tests were performed, what the doctor asked you, what the doctor asked you to do, and whether you had an opportunity to explain to the doctor what you felt were the symptoms of your condition.
Should a dispute arise regarding the propriety of the exam or the subsequent disability determination, the claimant may need to seek the advice of a Social Security - Disability attorney.