Consultative Examinations: A Guide for Health Professionals

Part III - Consultative Examination Guidelines

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 recontacting 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 medical source 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.

Social Security is committed to providing fair and equitable service to the American public, regardless of an individual’s inability to communicate effectively in English. Social Security  recognizes that using qualified interpreters efficiently facilitates the Agency’s processes, deters fraud, and assures that individuals with limited English proficiency (LEP) are not disadvantaged.  Therefore, the DDS will provide an interpreter free of charge, to any individual requesting language assistance, or when it is evident that such assistance is necessary to ensure that the individual is not disadvantaged.  Individuals have the option of using their own interpreter, such as a family member, friend, or third party, providing the interpreter meets the Agency’s criteria for interpreters.  A qualified interpreter is an individual or vendor who is able to read, write, and speak fluently in English and the language or dialect of the individual needing language assistance, and who meets the following criteria:

  • Provides an accurate interpretation of questions and responses by both the individual being interviewed and the CE provider; i.e., does not self-initiate follow-up questions or infer facts or dates not provided by the individual or the CE provider;
  • Demonstrates familiarity with basic terminology used in the disability determination process, including medical and social welfare terminology when necessary;
  • Agrees to comply with Social Security's disclosure and confidentiality of information requirements; and
  • Has no personal stake in the outcome of the case that would create a conflict of interest. An individual who is a potential or actual claimant or beneficiary on the same record as the individual needing language assistance can act as an interpreter, providing that there is no other conflict of interest.

 

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 sources who perform CEs must have a good understanding of SSA's disability programs and their evidence requirements. The medical source 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, medical sources are selected based on appointment availability, distance from a claimant's home and ability to perform specific examinations and tests.


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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 medical source'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 medical source who actually performed the examination. The medical source 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 CE report to determine whether the specific information requested has been furnished.

The CE report must:

  • Provide evidence that serves as an adequate basis for disability decisionmaking 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 examinationand 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 medical source and ask the medical source to furnish the missing information or prepare a revised report.