Effective Dates: 09/25/2020 - Present Previous | Next

TN 22 (09-20)

DI 22510.108 Adult Consultative Examination (CE) Report Content Guidelines for Skin Disorders

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

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

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

B. Report content specific to skin disorders

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

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Dates and results of relevant diagnostic procedures such as biopsy and genetic testing; and

b. Treatment modalities, dates of treatments, and responses to treatments.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Contractures or type of skin lesion(s) and extent of the body affected;

b. Duration of skin lesion(s);

c. Joint function including range of motion of the affected joint(s);

d. If there is involvement of the palmar and/or plantar surfaces, describe the effect on hand use and/or ambulation; and

e. Optional with consent of the claimant: a digital photograph to document the severity of the skin lesion(s).

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510108
DI 22510.108 - Adult Consultative Examination (CE) Report Content Guidelines for Skin Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020