TN 12 (11-12)

DI 22510.015 Information for Consultative Examination (CE) Source

Citations:

20 CFR 401.100 et seq., 404.1519n, 404.1519o, 416.919n, and 416.919o;

SSR 96-10p

A. Information to provide CE sources

Medical sources who perform CEs need information that provides a good explanation of the Social Security disability programs and the programs evidentiary requirements.

Explain the following information to new CE sources and to existing CE sources periodically.

1. CE scheduling information

CE appointments must allow sufficient time for the CE source to take a case history, when appropriate, and to perform the requested type of examination. For specific scheduling intervals, see DI 39545.250A.

2. CE report content

For detailed CE report requirements, see DI 22510.015B in this section.

3. Claimant identification

The CE report should include the claimant’s Social Security number and either:

  • documentation that the claimant provided proof of identity by showing a valid and current government photo identification (ID) (e.g., United States (U.S.) State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.),
    OR

  • a physical description of the claimant, to help ensure that CE source examines the claimant, unless the CE source is the claimant’s treating source.

4. CE signature requirement

For detailed signature requirements, see DI 22510.015C in this section.

5. CE report submission

Explain when and how the source should submit the CE report.

6. Rates of payment

Advise the CE source of the established rates of payment (fee schedules) and customary procedures for fee authorization.

See details:

7. Privacy Act information

Explain that the Privacy Act:

  • prohibits use of the examination report prepared for us (including background material furnished to the source);

  • strictly prohibits unauthorized disclosure of claimant information and subjects unauthorized disclosure to legal penalties;

  • gives the claimant access rights to records we maintain about him or her. Therefore, we cannot guarantee the CE source confidentiality.

8. CE source required referrals

Explain that the CE source must contact the Disability Determination Services (DDS) immediately when:

  • anyone, including the claimant, requests a copy of the CE report or associated records; see GN 03300.000.

  • the CE source is subject to a court order concerning the source’s CE records or related testimony. Instruct the CE source that he or she should provide the DDS with a copy of the court order, either by fax or by email. Explain to the CE source that he or she must wait for instruction from the DDS before releasing records or disclosing information in response to a request or court order.

NOTE: If the CE source notifies the DDS of a court order, contact the Associate Regional Commissioner for Management and Operations Support for case-specific instructions. See details in GN 03330.010.

B. CE report requirements

To provide reliable evidence, a CE report must reflect accepted professional medical standards and practice. When you need less than a complete CE report (e.g., you only need a specific laboratory test result to complete the file), you may not need every element listed in this section.

The detail and format for reporting the results of a CE will vary, depending on the type of examination or testing requested. Provide the CE source case-specific CE report requirements in writing; see details in DI 22510.017A.

1. Elements of a complete CE report

A complete CE involves all the elements of a standard examination in the applicable medical specialty. The report should be complete enough to show the nature, severity, and duration of the impairment and the claimant’s ability to function.

The medical report should include the following elements:

  • The claimant’s major or chief complaint(s) and any other abnormalities, or lack thereof, reported or found during examination or laboratory testing. (The report should reflect the claimant’s own statement of symptoms, not simply the CE source’s statements or conclusions.)

  • A detailed description, within the area of specialty of the examination, of the history of the major complaint(s).

  • A detailed description and disposition of pertinent “positive” and “negative” objective findings based on the history, examination, and laboratory tests related to the major complaint(s) and any other abnormalities, or lack thereof, reported or found during examination or laboratory testing.

  • The results of laboratory and other tests (e.g., x-rays) performed in accordance with the requirements stated in the Listing of Impairments.

  • Diagnosis and prognosis.

  • A medical opinion (MO) from the CE source expressing an opinion about what the claimant can still do despite his or her impairment(s).

2. Medical Opinions (MO) from CE sources

An MO is a medical opinion about the adult claimant’s ability to do work-related activities or, in child claims, the child’s ability to function. While we ordinarily request an MO as part of the CE process, the absence of an MO does not make a CE report incomplete. However, the report must be complete enough to enable an independent reviewer to determine the nature, severity and duration of the impairment(s) and, in adult claims, the claimant’s ability to perform basic work-related functions. See DI 22510.020B.3. for information regarding clarification of inadequate CE reports.

a. Requesting an MO

Request the CE source provide an MO that addresses functional abilities relevant to the CE and the claim.

b. When not to request an MO

Do not request an MO:

  • in statutory blindness claims, or

  • when the claimant is sent to a laboratory to only have objective testing, for example, a blood test.

C. CE report signature policy

The medical source who actually performed the examination must personally review and sign all CE reports.

The CE source signature attests that the source is solely responsible for the report contents and for the conclusions, explanations, or comments provided with respect to the history, examination, and evaluation of laboratory test results.

1. Acceptable CE report signatures are:

  • original written signatures, signed in ink, also known as “wet” signatures, on the original paper copy of the CE report;

  • facsimiles, photocopies, or scanned images of written (“wet”) signatures;

  • electronic signature attestations submitted through the Electronic Records Express (ERE) attestation process.

IMPORTANT: ERE is the only electronic signature technology approved by the agency for obtaining policy-compliant CE report signatures.

2. Reviewing CE report signatures for acceptability

For an explanation of how to adjudicate a claim with an unsigned or improperly signed CE report in file, see DI 22510.020C.

3. Reviewing CE reports for acceptable electronic signatures

Registered CE sources submit electronically signed copies of CE reports using the ERE “click and sign” feature. This produces an attestation that is electronically linked to, and included with, the CE report in the certified electronic folder (CEF). The ERE attestation reads:

“I am certifying, under penalty of perjury, that I have been authorized or contracted by the Disability Determination Services to examine the claimant named in the attached, and produced a consultative examination report for that claimant. The report is accurate. By checking the “I have read and agreed with the above” checkbox below, I am certifying that I personally conducted, or personally participated in conducting, the consultative examination and have electronically signed the report contained within.”

NOTE: For paper folders, the CE report must contain a printout of the ERE attestation along with the ERE signature. The ERE signature shows the printed name of the signer or the signer’s personal identification number (PIN)/user name; and the month, day, and year of the signature.

IMPORTANT: An electronic “signature” produced by a CE source’s own electronic recordkeeping system does not meet our requirements for an acceptable CE report signature.

4. Reviewing CE reports for acceptable non-electronic CE report signatures

The CE source signature, or an acceptable copy of the signature, must appear on the copy of the CE report in the disability folder.

Consider a CE report unsigned or improperly signed if it contains:

  • an annotation of “not proofed” or “dictated but not read”;

  • a rubber stamped signature of a medical source; or

  • the CE source's signature entered by any other person.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510015
DI 22510.015 - Information for Consultative Examination (CE) Source - 09/11/2017
Batch run: 09/11/2017
Rev:09/11/2017