This is a report that was published in the Southern Medical Journal
1995;88,3:256-259 March 1995.
It is of significant importance to Parkinson's families, care-givers
and their doctors. The point that this Dis-Ease becomes a disability
is determined by the patient.
For the "working Parkie or ET", you may discover that you can't make
it to retirement or until the kids are out of school. Your care-giver
may see that trying to continue on, is dangerous in your condition.
Dr. Scovern's work takes some of the mystery out of the application
for Social Security Disability. It stresses the point that your
physician needs to keep a record of your diagnosis and treatment,
relating how the progression of the different symptoms effect your
ability to work. He gives examples. Look them over and start relating
your symptoms with your doctor and their impact on WORK-RELATED
activities.
UPDRS and ADL over the duration supports your case.
Many Physicians, are still in the "dark" like Dr. Scovern was before
he became involved in Social Security, about what kind of information
was really needed. Print a copy of this paper for each of your
doctors.
---------------------------Start of Report------------------------------
Social Security Disability: Guidelines for Medical Practitioners
HENRY SCOVERN, MD, Philadelphia, Pa
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 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.
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.
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
-----------------------------------------------------------
THE APPLICATION EVALUATION PROCESS -
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 equiv-
alent 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 he considered disabled under this mechanism, the
individual must he unable to perform any job in the national
economy for which he is qualified. Specialized examiners use
publications such a 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.
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.
----------------------------------------------------------
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 0ffice of Disability at (410) 965-7673. Availability by
Internet is also planned.
----------------------------------------------------------
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.
0nset
The time at which limitation of work-related function
became significant enough to result in a finding of disability,
according to SSA regulations.
Severity
A determination of whether and to what degree a condition
limits an individual's physical or mental capacity to perform
basic work activities.
RFC
Residual Functional Capacity-an assessment of the remaining
capacity for work-related function.
-----------------------------------------------------------
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]), review
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.
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.
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.
----------------------------------------------------------
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
consistent 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.
----------------------------------------------------------
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.
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 non-invasive 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.
John Cottingham [log in to unmask] OR [log in to unmask]
