TN 11 (06-09)

DI 26510.089 Medical Consultant (MC)/Psychological Consultant (PC) Signature Requirements for Disability Determinations

Citations:

42 U.S.C. 421(h); 42 U.S.C. 1382c(a)(3)(H) and (I); 20 CFR 404.1503(e)/ 416.903(e) and (f); 404.1520a(d)(1)/416.920a(d)(1); 404.1526/416.926; 416.926a(c); 404.1527(f)(1)/416.927(f)(1); 404.1614/416.1014; 404.1615(c) and (d)/416.1015(c), (d), and (e); and 404.1616/416.1016.

A. Policy for MC/PC signature requirements

1. MC/PC Responsibilities

A team consisting of an MC or a PC and a disability examiner (DE) generally makes the disability determination. If there is no medical evidence in the file, the DE alone makes the determination (DI 24501.001B.1). In his or her role as an adjudicative team member, an MC or PC reviews all the relevant evidence in the case record and evaluates the medical issues, as required by DI 24501.001B.4.

The MC/PC is responsible for considering not only the total effect of a single impairment but also the combined effect of all impairments, including those that are not severe.

When the medical assessment is completed, the MC/PC’s signature on the appropriate form(s) is needed to confirm the consultant's agreement with, and responsibility for, the medical assessment portion of the disability determination.

NOTE: For limitations on what MCs (who are not physicians) or PCs can evaluate, refer to DI 24501.001B.4.

2. Document the effect of all impairments

By signing the appropriate medical assessment form(s) (DI 26510.089A.3.) and by checking the block, “These findings complete the medical portion of the disability determination,” the MC/PC confirms his or her responsibility for the medical evaluation portion of a disability determination as described in DI 26510.089A.1.

  • If there is a single impairment, then the appropriate medical assessment form(s) must document the total effect of the impairment.

  • If there are multiple mental impairments or multiple physical impairments, then the appropriate medical assessment form(s) must document the combined effect of all impairments.

  • If there is a combination of mental and physical impairments, then the medical assessment form(s) must document the combined effect of all impairments. This is accomplished when the MC/PC completes the appropriate medical evaluation forms (see DI 26510.089A.3). The combination of the appropriate medical evaluation forms documents overall medical severity. The DE or MC/PC must verify that the forms reflect the adjudicative team’s full assessment of the combined functional effects of all impairments and must choose which of the signatory consultants is most appropriate for reference on the disability determination form (if the MC/PC chooses not to sign the disability determination form) as required by DI 26510.089B.1.b.

  • If the MC/PC assessment is preliminary, advisory, or partial, then the DE must ensure that the MC/PC finalizes the assessment before the determination is made.

3. Appropriate medical assessment forms and disability determination forms

Appropriate medical assessment forms are:

  • SSA-2506-BK (Psychiatric Review Technique),

  • SSA-4734-BK (Physical Residual Functional Capacity Assessment),

  • SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment), or

  • SSA-538-F6 (Childhood Disability Evaluation Form) for Title XVI childhood disability cases.

In Title II and Title XVI adult cases, the Disability Determination Services (DDS) may use an existing federal form (for example, the SSA-416 (Case Analysis)) or local form to document medical assessments of physical impairments that are not severe or that meet or equal a Listing.

Disability determination forms are:

  • SSA-831-C3/U3 (Disability Determination and Transmittal),

  • SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal Title XVI), or

  • SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal Title II).

4. Requirements for actual signature on medical assessment and disability determination forms

The signature requirements for medical assessment forms and disability determination forms are as follows:

  • Each medical assessment form must have a reviewing MC/PC’s actual physical signature or an approved electronic signature—unless the DE is a single decisionmaker (SDM). In SDM sites, the SDM may sign the medical assessment form in Title II and Title XVI initial adult claims (except in the instances where an MC/PC signature is statutorily required, i.e. less than fully favorable mental impairments).

  • An MC/PC must sign an SSA-538-F6 in every Title XVI childhood disability case decided by the DDS (DI 25230.001).

  • An MC/PC signature is not required when there is no medical evidence of record. In such a case, the DE makes the disability determination by completing and signing the disability determination form (DI 24501.001B.1).

  • An MC/PC is not required to sign the disability determination form. See DI 26510.089B.1.b., DI 26510.090, and DI 81020.130.

  • If the MC/PC chooses not to sign the disability determination form and there is a signed medical assessment form that completes the medical portion of the claim, then the DE must select which signed medical assessment form is most appropriate for reference on the disability determination form as required by DI 26510.089B.1.b.

NOTE: If a combination of mental and physical impairments affects the determination, then the DE must cite the assessment form signed by the MC.

B. Procedure for signature on the medical assessment and disability determination forms

Once the MC/PC completes the medical portion of the disability determination, he or she must choose one of the following signature options:

  • Sign only the appropriate medical assessment form(s), as instructed in DI 26510.089B.1.a.; or

  • Sign both the disability determination form(s) and the appropriate medical assessment form(s), as instructed in DI 26510.089B.2.

1. MC/PC signs only the medical assessment form

a. MC/PC actions

Review the case. On the SSA-416, SSA-2506-BK, SSA-4734-BK, SSA-4734-F4-SUP, SSA-538-F6, or other local medical assessment form, document the determination as follows:

  • Complete the required case analysis;

  • Check the block on the form: “These findings complete the medical portion of the disability determination”; and

  • Sign, date, and enter the consultant’s specialty code.

NOTE: The MC/PC does not check this block when the MC/PC’s assessment is preliminary, advisory, or partial. If the MC/PC later finalizes this assessment, then the MC/PC may either check the block on the form “These findings complete the medical portion of the disability determination” or sign the disability determination form, as instructed in DI 26510.090.

b. DE actions

If the MC/PC does not sign the disability determination form, then the DE must complete it and enter the following information:

  • “See (cite medical assessment form dated (enter date))” (in SSA-831-C3/U3, Item 32; SSA-832-C3/U3 or SSA-833-C3/U3, Item 27).

  • The MC/PC’s name (in SSA-831-C3/U3, Item 32A; SSA-832-C3/U3 or SSA-833-C3/U3, Item 30).

  • The MC/PC’s specialty code (in SSA-831-C3/U3, Item 32B; SSA-832-C3/U3 or SSA-833-C3/U3, Item 30A).

2. MC/PC signs both the disability determination form and the appropriate medical assessment form

If the MC/PC signs both the disability determination form(s) and the appropriate medical assessment form(s), he or she does not need to check off the statement on the medical assessment form(s) certifying that the findings complete the medical portion of the determination. He or she should complete the relevant items on the disability determination form(s) as described in DI 26510.090.

NOTE: If there is a combination of mental and physical impairments that affects the determination, then only the MC may sign the disability determination form.

C. Procedure when multiple medical assessment or disability determination forms are in the file

At each level of adjudication:

  • Retain all medical assessment and disability determination forms that reflect the final determination made in the case.

  • Move any medical assessment or disability determination form that does not reflect the final determination of that adjudicative level (for example, forms that are partial or preliminary) to the temporary section of the certified electronic or paper folder. These forms will be deleted from the file at case closure.

  • Do not remove any medical assessment or disability determination forms from previous adjudications.

  • Cases involving federal quality assurance review may require the creation of corrected medical assessments and disability determination forms. These should be handled in accordance with the instructions in DI 30005.236C. and DI 81020.135F.2.


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DI 26510.089 - Medical Consultant (MC)/Psychological Consultant (PC) Signature Requirements for Disability Determinations - 10/25/2011
Batch run: 10/25/2011
Rev:10/25/2011