TN 22 (09-20)

DI 22510.114 Adult Consultative Examination (CE) Report Content Guidelines for Immune System Disorders

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

A. General guidelines for CE report content for immune system disorders

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

B. Report content specific to immune system disorders

The CE provider will use the specific requirements below to complete the CE report for an immune system disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Weight loss;

b. Fever;

c. Pain;

d. Fatigue;

e. Malaise;

f. Degree of limitation in:

1. Activities of daily living;

2. Maintaining social functioning; and

3. Completing tasks in a timely manner due to deficiencies in concentration, persistence, and pace; and

g. Effects in other organ systems.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Signs of affected body systems, such as heart, lungs, kidneys, eyes, digestive system, skin, etc.;

b. Any apparent abnormalities such as gait or the need for any type of assistive device;

1. If the claimant uses an assistive device(s), note the type of, and medical need for, the device.

2. For lower extremity assistive devices, describe the claimant’s gait with and without use of the device.

b. Ability to:

1. Tandem walk;

2. Walk on heels and toes;

3. Bend;

4. Squat;

5. Get up from a seated position;

6. Grasp or shake hands;

7. Write; and

8. Turn door handles.

c. Extremities and peripheral joints:

1. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;

2. Effusion;

3. Periarticular swelling;

4. Tenderness;

5. Redness;

6. Heat;

7. Thickening;

8. Structural deformities;

9. Instability;

10. Grip, pinch, and ability to fully close the fist (either by dynamometer or 0-5 scale);

11. Extremity strength (either by dynamometer or 0-5 scale);

12. Atrophy; and

13. Ability to use, and effective use of, any orthoses.

d. Spine:

1. Distribution of pain, tenderness, sensory or motor loss; and

2. Active range of spinal motion;

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510114
DI 22510.114 - Adult Consultative Examination (CE) Report Content Guidelines for Immune System Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020