Effective Dates: 09/25/2020 - Present Previous | Next

TN 22 (09-20)

DI 22510.107 Adult Consultative Examination (CE) Report Content Guidelines for Hematological Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with hematological disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report for adult hematological disorders

The CE report guidelines for adult hematological disorders in this section are in addition to the general CE report content guidelines in DI 22510.100.

B. Report content specific to hematological disorders

The CE provider will use the specific requirements below to complete the CE report for a hematological disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Dates and results of relevant diagnostic procedures such as complete blood count (CBC), mean corpuscular volume (MCV), platelets, reticulocyte count, serial hemoglobin, hemoglobin electrophoresis, blood smears, and bone marrow examination; and

b. A detailed description of the following:

1. Abnormal blood clotting;

2. Pain crises;

3. Infections; and

4. Frequency of red blood cell (RBC) or other blood component transfusions or infusions.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Any apparent abnormalities such as pallor, jaundice, abnormal bruising, petechiae, ecchymoses, edema, fatigue level, or enlarged lymph nodes;

b. Joint examination including swelling, tenderness, and range of motion;

c. Abdominal examination including liver, spleen, or abnormal masses;

d. General and focal neurologic examinations; and

e. Mental status examination.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510107
DI 22510.107 - Adult Consultative Examination (CE) Report Content Guidelines for Hematological Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020