TN 22 (09-20)

DI 22510.105 Adult Consultative Examination (CE) Report Content Guidelines for Digestive Disorders

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

A. General guidelines for CE report content for adult digestive disorders

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

B. Report content specific to digestive disorders

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

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Fatigue, muscle weakness, sensory abnormalities, cognitive impairment, malaise, loss of appetite;

b. Sleep disturbance and any other nocturnal symptoms;

c. Pain, if present, and its location;

d. Recent (involuntary) weight loss and the amount;

e. Bowel and bladder patterns;

f. Nausea; and

g. Dates and results of relevant diagnostic procedures (such as diagnostic imaging, endoscopy, biopsy, aspiration of ascetic fluid, and clinical laboratory test).

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Presence of jaundice and pallor;

b. Liver and spleen size;

c. Muscle wasting;

d. Presence of edema, ascites, and asterixis;

e. Presence of any abdominal masses;

f. Rectal bleeding (if the claimant allows the physician to observe his/her rectum);

g. Evidence of perineal disease; and

h. Superficial manifestations of liver disease, such as, spider angiomas, caput medusae, and/or altered venous flow on the abdomen.

3. Laboratory tests or findings

The CE provider will obtain laboratory testing only after receiving proper authorization from the DDS. Describe and discuss the results of such tests as appropriate:

a. Serum creatinine;

b. Serum total bilirubin;

c. International normalized ratio (INR);

d. Serum albumin; and

e. Hemoglobin.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510105
DI 22510.105 - Adult Consultative Examination (CE) Report Content Guidelines for Digestive Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020