Title:
Social security disability: Guidelines for medical practitioners. By: Scovern,
Henry, Southern Medical Journal, 00384348, Mar95, Vol. 88, Issue 3
Database:
Academic Search Complete
SOCIAL SECURITY DISABILITY: GUIDELINES FOR MEDICAL PRACTITIONERS
Section: SPECIAL ARTICLE
ABSTRACT: The purpose of this paper is to introduce medical practitioners to
the concepts and function of the Social Security Administration's process of
awarding disability benefits. Better understanding of this massive and
important program will enable physicians to focus on and present appropriate
information. This will facilitate processing of applications to the benefit of
physicians, patients, and society.
The Social Security Administration of the Department of Health and Human
Services (HHS) received 3,611,377 applications for disability benefits during
fiscal year 1994 and expects as many as 3.9 million applications in fiscal year
1995. In processing applications, the SSA requests medical information from
practitioners of all specialties. Unfortunately for practicing physicians, this
branch of government and its mode of function can seem like a "black box." Few
if any medical schools and postgraduate programs devote time to disability
issues in general or to Social Security disability in particular. Because of
this lack of understanding, considerable physician time is wasted in providing
information that does not further the evaluation of disability, and physicians
can become frustrated with the system. Before becoming involved as a medical
case reviewer, I was mystified by the process of Social Security disability and
was upset and confused about requests for information and about the results I
saw. At times it seemed that the applications of patients who were severely
incapacitated were arbitrarily denied, while those of individuals with vague
complaints were allowed. In my current capacity I learned that the system is
rational, though at times cumbersome, and is largely codified by law, judicial
review, and structured policy-making procedure.
This paper is an attempt to introduce physicians who care for adult patients
with medical and surgical illness to the salient aspects of the Social Security
Administration's disability evaluation process. Although there are
similarities, the SSA's approach to the medical evaluation of disability in
children and patients with psychiatric illness is significantly different and
is not addressed in this paper.
[Marker]BACKGROUND INFORMATION [ ]
There are two broad Social Security disability programs (Table 1). Title II, or
Social Security Disability Insurance (SSDI), may be regarded as a contract
between the government and a participating worker. It covers individuals who
have engaged in meaningful work activity but are no longer able to work because
of a medical condition. It is analogous to an insurance policy that is earned
by engaging in work activity and is financed through the Social Security tax.
Title XVI, or the Supplemental Security Income program (SSI), replaced separate
state programs for needy persons and is financed and administered by the
federal government through general revenues. There is no qualifying work
requirement, but there is a limit on the amount of income and resources that a
person can have and still be eligible. From the medical evaluation standpoint,
the programs are treated identically.
[Marker]THE APPLICATION EVALUATION PROCESS [ ][Marker]SSA Definition of
Disability [ ]
According to law, medical factors that might contribute to disability must be
evaluated to determine whether the applicant has an impairment that is severe
enough to have more than a minimal impact on work-related activity (Table 2)
and:
(a) is listed in the Listing of Impairments* or is equivalent in severity; or
(b) prevents the individual from engaging in a previous occupation and the
individual's physical and/or mental capacities, age, education, and vocational
experience do not permit adjustment to work different from that performed in
the past. To be considered disabled under this mechanism, the individual must
be unable to perform any job in the national economy for which he is qualified.
Specialized examiners use publications such as the Dictionary of Occupational
Titles to determine the physical demands for various job titles.
To be considered disabling under Social Security law, a condition must be
expected to last 12 months or to result in death.
[Marker]Onset [ ]
In the SSDI program, "onset" (ie, when disability began) can be retroactive. In
other words, the disabled individual may be eligible to receive benefits for a
period of time before he actually filed the claim. Therefore, if the SSDI
applicant is deemed disabled, onset becomes an important consideration.
[Marker]Severity and Residual Functional Capacity [ ]
To determine the severity of the applicant's medical condition ("severity") and
the remaining capacity for work-related function ("residual functional
capacity" [RFC]), re-view of medical records is undertaken by trained lay
individuals and physicians who are employed by or who contract with SSA.
Sufficient objective data must be obtained so as to enable the SSA reviewer to
independently assess severity and RFC. Existing data provided by treating
physicians is given the most weight as it offers the benefits of personal and
longitudinal observation. However, if the treating source material is
inadequate, then additional information must be obtained from a purchased
"consultative examination" directed toward the applicant's alleged complaints.
[Marker]Consultative Examinations. [ ]
Treating physicians are encouraged to provide these consultative examinations.
If the treating physician can not or is not qualified to perform the
specialized examination, it is purchased from one of a panel of local
physicians. Usually the physician performing the consultative examination is
given a list of specific questions to be addressed (in addition to obtaining
any other relevant historical and physical findings). The role of the examining
physician is to identify relevant historical and physical examination findings
and submit a detailed report pertaining to any condition that could affect the
applicant's ability to function in the work place. Conclusions regarding
specific capabilities should be buttressed by the objective data.
[Marker]Postevaluation Procedure. [ ]
If medical factors support the applicant's contention of disability, an
administrative eligibility evaluation takes place. For instance, to be awarded
benefits, the applicant must not be engaged in work activity that provides
substantial remuneration. In the absence of adverse administrative factors,
benefits are then awarded.
If consideration of the medical and administrative factors leads to denial of
the application, a sequential appeals process is available. The applicant may
ask for reconsideration of the same evidence or may furnish supplementary
evidence. If the application is again unsuccessful at the reconsideration
level, it may be appealed further to an administrative law judge. Applicants
may retain an attorney at any phase of the process. Fees are billed at an
hourly rate but are payable only on a contingency basis. In certain allowed
claims situations, attorney fees may be deducted from benefits that have
previously accrued, not to exceed 25% of the past due benefits.
[Marker]ROLE OF THE TREATING PHYSICIAN [ ]
Medical information is requested from all sources identified by the applicant.
Ordinarily, the treating physician(s) is most aware of the applicant's history
and current functional status, and information so provided is given emphasis.
Unfortunately, much of what is received from hospitals and treating physicians
is not suitable for evaluation of disability, because it either lacks
information relevant to the applicant's ability to perform work-related
activity or it is too subjective. Unsupported statements such as "This
applicant is disabled" are frequently received, but do little to further the
evaluation of the claim. Alternatively, the medical records may sufficiently
clarify the present situation but fail to support retroactive benefits because
of inadequate longitudinal record keeping.
Specialized knowledge of the physical capabilities required for work is beyond
the scope of most medical activity. Sometimes one can appreciate these concepts
intuitively, eg, that good function of the hands and shoulders and intact
ability to stoop, lift, and carry would be very important to an individual
without other training who had spent a 20-year career exclusively in the
construction trades. However, the treating physician is not expected to have
such knowledge, nor to provide conclusions about disability. Instead, the
essential role (Table 3) is to provide objective medical documentation along
with dates to enable Social Security personnel to independently determine
severity, RFC, and onset according to Social Security regulations. If the
physician feels capable, his assessment of the applicant's remaining
physical/mental capacity, which is consistent with the objective medical
evidence, should also be provided. Subjective factors (eg, pain) and historical
statements about daily functioning should be supported by the reported
objective findings. Relevant radiologic and laboratory data should be
forwarded, and any circumstances that compound the applicant's situation should
be presented.
[Marker]Emphasis on Functional Assessment [ ]
In contrast to most of medicine in which the physician evaluates the progress
of a disease, dysfunction (regarding work-related activity) is the primary
focus of disability evaluation. Therefore, findings should be reported in terms
of the mechanisms by which the disease(s) causes work-related dysfunction and
should be consistent with the stage of the applicant's disease process. Several
examples follow for illustrative purposes. If an individual suffered arthritis,
the musculoskeletal examination would be key. Relevant information would
include range of motion, evidence of inflammation or deformity, ability to
maneuver for the examination (dress, undress, change positions on the
examination table, etc), fine motor function (writing, picking up coins,
buttoning clothes, etc), and gross motor function (gait, grip strength, formal
muscle strength testing, etc). Similar clinical information would be needed for
an individual with a hemiparesis. Emphasis would be placed on gait, need for an
ambulatory assistive device, fine and gross motor function, and communicative
or visual dysfunction. For an individual with emphysema, respiratory rate, use
of accessory muscles, signs of respiratory difficulty during the examination,
diminished breath sounds, cyanosis, signs of heart failure, history of repeated
hospitalization, need for supplemental oxygen, findings on chest films,
arterial blood gas values, and results of pulmonary function studies would
facilitate evaluation. Ischemic heart disease would be supported by complaints
suggestive of angina or congestive heart failure, results of invasive and
noninvasive cardiac testing, physical findings of congestive heart failure, and
documentation of myocardial infarction. Many diseases (AIDS, inflammatory bowel
disease, cancer, systemic vasculitis, systemic lupus, etc) can cause
dysfunction on the basis of multifocal involvement or on the basis of
generalized debility, weight loss, need for repeated operative procedures, and
secondary complications. Evaluation requires accurate information on the
clinical process and the time course of its progression. The Medical Listings
are organized by body system and provide the framework for the Social Security
medical evaluation process. Discussion of each impairment, according to
Listing, is beyond the scope of this paper. However, physicians can use the
Medical Listings and the accompanying explanations as a guide to parameters
Social Security uses to gauge severity.
Following an initial adaptation period and learning curve, it soon becomes
routine to incorporate critical information related to potential disability
into the interview, examination, and progress notes. If such information were
consistently provided to the Social Security Administration, the efficiency and
effectiveness of the disability evaluation process would be greatly enhanced,
to everyone's benefit.
[Marker]TABLE 1. Administrative Terms [ ]
HHS = Department of Health and Human Services
SSA = Social Security Administration, an agency within
HHS
SSDI = Social Security Disability Insurance, a Social
Security disability insurance program; eligibility is
earned through work
SSI = Supplemental Security Income, a Social Security
disability program administered as an entitlement
[Marker]TABLE 2. Operational Terms [ ]Medical Listings
The Listing of Impairments, which is organized by body system, enumerates
conditions which are considered by SSA to cause severe impairment of physical
and mental function. It is used by Social Security to gauge the work-related
severity of an applicant's condition. If an applicant's condition meets the
requirements of the Listing or is equal in severity, from a medical standpoint
disability is assumed. If an applicant has a severe condition short of the
conditions stated in the Listings, further assessment of RFC, background,
training, and education is required for adjudication of the claim.
[Marker]Onset [ ]
The time at which limitation of work-related function became significant enough
to result in a finding of disability, according to SSA regulations.
[Marker]Severity [ ]
A determination of whether and to what degree a condition limits an
individual's physical or mental capacity to perform basic work activities.
[Marker]RFC [ ]
Residual Functional Capacity---an assessment of the remaining capacity for
work-related function.
[Marker]Table 3. Principles of Effective Patient Data Reporting for Social
Security Disability Purposes. [ ]
Report disease process(es), with particular emphasis on
objective findings with work related, functional impact.
Report the time course of the functional consequences in
terms of their first appearance and expected duration.
Support statements with objective findings through physical
examination findings and radiologic, laboratory, and hospital
records.
Subjective complaints (eg, pain, fatigue,etc) must be
consistant with the stage of the disease process and the objective
findings.
Copies of longitudinal office notes are best, if they are
legible and the essential information is present.
[Marker]REFERENCE [ ]
*The Listing of Impairments for Adults has been extensively updated recently.
Therefore the SSA is now preparing a revised handbook for physicians. It is
scheduled for release during the fall of 1994. To receive a copy of the
publication, which is entitled "Disability Evaluation Under Social Security,"
contact the SSA Office of Disability at (410) 965-7673. Availability by
Internet is also planned.
~~~~~~~~
By HENRY SCOVERN, MD, Philadelphia, Pa
From the Department of Internal Medicine, Hahnemann University, Philadelphia,
Pa
The statements herein are those of the author and should not be construed as
statements of policy by the Social Security Administration
Correspondence to Henry Scovern, MD, 725 Conshohocken State Rd, Bala Cynwyd, PA
19004-2102. (Reprints not available.)
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