TN 23 (09-20)

DI 22510.038 Pediatric Consultative Examination (CE) Report Content Guidelines for Special Senses and Speech

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 special senses and speech 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 pediatric CE report content guidelines for speech disorders and language disorders, see DI 22510.055 and DI 22510.060. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric visual disorders

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

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Character and severity of visual loss;

b. Dates and results of relevant diagnostic procedures, such as imaging studies, visual acuity testing, and visual field testing.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Best corrected visual acuity for each eye, and the manifest refraction for each eye.

1. If there is a loss of visual acuity, document the cause of the loss.

2. If the vision loss is due to a cortical visual disorder, it must be confirmed by documenting the cause of the brain lesion.

b. For children who do not have the ability to participate in visual acuity testing using Snellen methodology or other comparable testing, clinical findings of fixation and visual-following behavior.

c. Examination of pupils, external exam, and extraocular motions.

d. Visual fields – confrontation visual fields.

1. If confrontation fields are not normal, or if there is a history of glaucoma, visual field testing is needed;

2. Confrontation fields are acceptable evidence that the fields are normal. Restricted fields must be confirmed either by acceptable automated static threshold perimetry, measuring the central 24 to 30 degrees of the visual field performed on an acceptable perimeter (acceptable test include the Humphrey Field Analyzer (HFA) 30-2, Octopus 32, Octopus 30-2, and HFA 24-2); or an acceptable manual or automated kinetic perimetry (for example, Goldmann perimety);

3. Include a printout of any visual field testing (perimetry) results; and

4. If there is a loss of visual fields, document the cause of the loss.

e. Intraocular pressure for each eye;

f. Slit lamp exam – cornea and lens, at least;

g. Fundus exam – discs, vessels, and maculae, and peripheral retina; and,

h. Any observed visual behaviors (for example, ability to navigate in the office, reaching for items, using cell phone in waiting room).

C. Report content specific to pediatric hearing loss

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Character and severity of hearing loss; and

b. Dates and results of relevant diagnostic procedures, such as audiometry, tympanography, and MRI.

2. Physical examination

The CE provider will describe and discuss as appropriate:

a. Examination of the ears, nose, and throat;

b. An otologic examination:

1. The external ears (pinnae and external ear canals) and the tympanic membranes; and

2. Any middle ear abnormalities

c. Hearing loss:

1. The condition that causes the hearing loss; and

2. Whether the hearing loss is sensorineural, conductive, or mixed.

d. All audiometric testing performed where no cochlear implant or bone-anchored hearing aid (BAHA) is present should be conducted unaided.

e. For children without a cochlear implant(s) from birth to the attainment of age 6 months, physiologic testing, such as auditory brainstem response (ABR) testing.

f. For children without a cochlear implant(s) who are age 6 months to the attainment of age 2, air conduction thresholds determined by a behavioral assessment, usually visual reinforcement audiometry (VRA) or ABR testing, if the behavioral assessment cannot be completed.

g. For children without a cochlear implant(s) who are age 2 to the attainment of age 5, air conduction thresholds determined by a behavioral assessment, such as conditioned play audiometry (CPA), tangible or visually reinforced operant conditioning audiometry (TROCA, VROCA), or VRA.

h. For children without a cochlear implant(s) who are age 5 and older:

1. Pure tone air conduction and bone conduction testing, speech recognition threshold (SRT) testing, and word recognition testing;

2. Testing must be done in a sound-treated booth or room;

3. Testing must be done in accordance with the most recently published standards of the American National Standards Institute (ANSI);

4. Each ear must be tested separately; and

5. If the SRT is not within 10 dB of the average pure tone air conduction thresholds at 500, 1,000, and 2,000 Hz, document the medical basis for the discrepancy.

i. For children with a cochlear implant(s) who are age 5 and older:

1. Sentences presented at 60 dB hearing level and without any visual cues;

2. In a quiet and sound field; and

3. With the cochlear implant in place, functioning properly, and adjusted to the child's normal settings.

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510038
DI 22510.038 - Pediatric Consultative Examination (CE) Report Content Guidelines for Special Senses and Speech - 04/28/2000
Batch run: 09/25/2020
Rev:04/28/2000