TN 23 (09-20)

DI 22510.040 Pediatric Consultative Examination (CE) Report Content Guidelines for Cardiovascular Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric cardiovascular disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric cardiovascular disorders

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

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Dyspnea;

b. Orthopnea;

c. Exercise intolerance;

d. Hypercyanotic spells;

e. Slow feeding;

f. Squatting;

g. Syncope; and

h. Growth failure.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Whether respiratory rate is labored or unlabored;

  2. b. 

    O2 saturation level;

  3. c. 

    Evidence of cyanosis (perioral, peripheral), pallor, and clubbing;

  4. d. 

    Heart sounds and murmurs;

  5. e. 

    Presence of hepatomegaly and edema; and,

  6. f. 

    Exercise tolerance test (ETT). The CE provider will obtain ETT only after receiving proper authorization from DDS. Use ETT for children age 6 and older, and perform as specified in section 104.00B7 of the cardiovascular listing (see DI 34005.104).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510040
DI 22510.040 - Pediatric Consultative Examination (CE) Report Content Guidelines for Cardiovascular Disorders - 01/23/1996
Batch run: 09/25/2020
Rev:01/23/1996