TN 10 (04-09)

DI 26510.045 Completing Item 22 (Regulation Basis Code) on the SSA-831

A. Title II

Enter the appropriate “Regulation-Basis” code under which the claimant is allowed or denied.

NOTE: The Reg-Basis Code should reflect the nature of the allowance or denial at the time of adjudication. However, in denials, when a technical requirement is no longer met, the Reg-Basis Code should reflect the nature of the denial at the time the technical requirement was last met.

Select the appropriate code from the reference charts in DI 26510.045C, in this section.

  • In closed period cases, enter the appropriate Reg-Basis Code applicable to that portion of the determination which reflects that the claimant was found to be disabled. Whenever the Central Office or Disability Quality Branch returns a determination for further consideration, enter the Regulation-Basis Code that is applicable to any new determination that is prepared. For a description of the various bases for determination refer to DI 26510.045C in this section.

  • When the regulation basis code of the original determination is unavailable, enter “CE” in Item 22. See “Collateral Estoppel – New Regulation Basis Codes” in DI 27515.060. See “Collateral Estoppel – New Regulation Basis Codes” in DI 27515.060. However, if known, the original regulation basis code should be entered here.

  • A claim denied on the basis of res judicata requires the entry “S1” in Item 22. (See DDS Action on Subsequent Title II Claim -- Claimant Previously Denied Through Date Last Insured/Prescribed Period/Age 22, DI 27516.005B.3.)

NOTE: It is no longer necessary to code a regulation number along with the Regulation Basis code because the National Disability Determination Services System only captures the Regulation Basis code for management information purposes.

NOTE: When adjudicating CDB re-entitlement claims, refer to notes in Childhood Disability Beneficiary (CDB) Re-entitlement, DI 23505.010A and Requirements for Re-entitlement, DI 10115.035A for a change in the re-entitlement period.

                                           

DIB/DWB Claim—Denial

Basis for Decision

Enter in Item 22 Reg-Basis Code

 

ER1 or PP1 Last met on or after date of current decision

ER1 or PP1 last met prior to date of current decision

Impairment Not Severe—Medical Consideration Alone

F12

F2

Capacity for SGA—Any Relevant Past Work

H1

H2

Capacity for SGA—Other Than Relevant Past Work

J1

J2

Engaging in SGA—(DIB claims only)

N13

N23

Impairment Prevented SGA for a Period of Less Than 12 Months

E1

E2

Impairment Prevents SGA at Time of Adjudication but is not Expected to Prevent SGA for a Period of 12 Months

E3

E4

Insufficient Evidence Furnished

M54

M65

DAA Is Material to the Determination of Disability

Z1

Z2

Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence

L1

L2

NH Does Not Want to Continue Development of Claim—Wants Decision Made on Evidence in File

M3

M4

NH Does Not Want to Continue Development of Claim—Does Not Indicate Decision to be Made on Evidence in File

M7

M8

NH Willfully Fails to Follow Prescribed Treatment

K1

K2

DWB Medicare Only Case—EOD at or after Age 62 Years and 7 Months—No Prior Disability Benefit Entitlement or Not Disabled, Whereabouts Unknown

X3

X3

1 ER (earnings requirement); PP (prescribed period).

2 Also use this Reg-Basis Code in situations where the claimant only meets the fully insured requirement at AOD or later, has alleged a visual impairment, and the claimant does not meet the definition of statutory blindness.

3 Use this code if the FO has determined that the claimant is engaging in SGA, the claimant alleges a visual impairment and the DDS determines that the claimant is not statutorily blind.(See Item 22 (Regulation Basis Code – Procedure – Title II – DIB-SGA Alleged, DI 26010.040C. )

4 Do not use M5 when the claimant cooperated but there is insufficient evidence of disability. In these situations, use F1.

5 Do not use M6 when the claimant cooperated but there is insufficient evidence of disability relating to the period before the insured status requirement was last met. In these situations, use F2.

 DIB/DWB Claim – Allowance

Basis for Decision

Enter in Item 22
Reg-Basis Code

Impairment Meets Level of Severity of Listings

A11

Impairment Equals Level of Severity of Listings

B1

Medical and Vocational Considerations

C1

Medical and Vocational considerations

(35-40 Years of Arduous Unskilled Work, Marginal Education, and Significant Impairment)

D1

1 When the date of onset (in item 15A) is based on statutory blindness, but the claimant is found not disabled for cash benefit purposes (item 18A), enter Regulation-Basis code "A1."

CDB Claim—Denial

Basis for Decision

Enter in Item 22

Reg-Basis Code

 

CDB Claim, or reentitlement CDB claim and re-entitlement period (RP) last met on or after date of current decision

Reentitlement CDB claim and RP last met prior to date of current decision

Impairment Not Severe—Medical Consideration Alone or Condition Disabling but did not Exist Before Age 22

F1

F2

Capacity for SGA—Vocational Considerations

G1

G2

Impairment Prevented SGA for a Period of Less Than 12 Months

E1

E2

Impairment Prevents SGA at Time of Adjudication but is Not Expected to Prevent SGA for a Period of 12 Months

E3

E4

Insufficient Evidence Provided

M51

M62

Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence

L1

L2

Claimant Does not Want to Continue Development of Claim

M3

M4

Claimant Willfully Fails to Follow Prescribed Treatment

K1

K2

Drug Addiction and/or Alcoholism is Material to the Determination of Disability

Z1

Z2

1 M5 is not used when the claimant has cooperated but there is insufficient evidence before age 22 to establish disability - use F1 instead.

2 M6 is not used when the claimant has cooperated but there is insufficient evidence before the end of the reentitlement period to establish disability - use F2 instead.

                                                   

CDB Claim—Allowance

Basis for Decision

Enter in Item 22 Reg-Basis Code

Impairment Meets Level of Severity of Listings

A1

Impairment Equals Level of Severity of Listings

B1

Medical and Vocational Considerations

C1

Parent Determination—Denial

Basis for Decision

Enter in Item 22 Reg-Basis Code

Impairment Not Severe—Medical Considerations Alone

F1

Capacity for SGA—Any Relevant Past Work

H1

Capacity for SGA—Other Than Relevant Past Work

J1

Impairment Prevented SGA for a Period of Less Than 12 Months

E1

Impairment Prevents SGA at Time of Adjudication but Is Not Expected to Prevent SGA for a Period of 12 Months

E3

Insufficient Evidence Furnished

M5

Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence

L1

NH Does Not Want to Continue Development of Claim

M3

NH Willfully Fails to Follow Prescribed Treatment

K1

                                             Parent Determination—Allowance

Basis for Decision

Enter in Item 22 Reg-Basis Code

Impairment Meets Level of Severity of Listings

A1

Impairment Equals Level of Severity of Listings

B1

Medical and Vocational Considerations

C1

Medical and Vocational Considerations (35-40 Years of Arduous Unskilled Work, Marginal Education, and Significant Impairment)

D1

B. Title XVI

  • Enter the appropriate Regulation-Basis Code. The code should reflect the nature of the allowance or denial at the time of adjudication.

  • Use a regulation basis code that reflects disability rather than blindness if the claimant was disabled in the month of filing and became statutorily blind in a later month.

  • In closed period cases, enter the appropriate regulation basis code applicable to the portion of the determination that reflects that the claimant was found to be disabled.

  • When the regulation basis code of the original determination is unavailable, enter “ACE” in Item 22. See “Collateral Estoppel – New Regulation Basis Codes” in DI 27515.060”. However, if known, the original regulation basis code should be entered here

  • Enter the regulation basis code that is applicable to any new determination prepared whenever a determination is returned by CO or DQB for further consideration.

NOTE: It is no longer necessary to code a regulation number along with the Regulation Basis code because the National Disability Determination Services System only captures the Regulation Basis code for management information purposes..

                                  

DI OR DS AI, AS, Claim—Denial
  DC Claim and Claimant Age 18-21—Denial
Basic for Decision isEnter in Item 22 Reg-Basis Code
 

No Visual Impairment1

Visual Impairments2

Impairment Not Severe-Medical Consideration Alone

N30

N414

Capacity for SGA—Any Relevant Past Work

N31

N42

Capacity for SGA—Other than Relevant Past Work

N323

N433

Engaging in SGA

N33

N335

Impairment Prevented SGA for a Period of Less Than 12 Months

N34

N45

Impairment Prevented SGA at Time of Adjudication But is Not Expected to Prevent SGA for a Period of 12 Months

N35

N46

Insufficient Evidence Furnished

N36

N36

Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence

N37

N37

Applicant Does Not Want to Continue Development of Claim

N38

N38

Applicant Willfully Fails to Follow Prescribed Treatment

N396

N396

1 Enter the applicable Reg-Basis Code from this column when the applicant does not allege a visual impairment.

2 Enter the applicable Reg-Basis Code from this column when the applicant alleges a visual impairment.

3 Also use this code when the applicant has the capacity for SGA but does not have a work history.

4 Also use this code in a multi-category case when a disability recipient is determined not to be statutorily blind.

5 Use this code if the FO has determined that the claimant is engaging in SGA, the claimant alleges a visual impairment and the DDS determines that the claimant is not statutorily blind. Use code N33 for both Engaging in SGA Without or With a Visual Impairment denials. Complicated systems changes prevent a new Regulation Basis Code from being created at this time. Code N44, formerly used in Engaging in SGA with a Visual Impairment denials, was redefined for use in DC Under Age 18 Impairment Not Severe denials.

6 Also use this code along with the appropriate DAA indicator code, when DAA is material to the determination of disability.


                                          DI, or DS, AI, AS Claim—Allowance
                                  DC Claims and Claimant Age 18-21—Allowance

Basis for Decision

Enter in Item 22

Reg-Basis Code

Impairment Meets Level of Severity of Listings

A61

Impairment Equals Level of Severity of Listings

A62

Medical and Vocational Considerations

A63

Medical and Vocational Considerations

(35-40 Years of Arduous Unskilled Work, Marginal Education, and Significant Impairment)

A64

                                               BI or BS Claim - Allowance

Basis for Decision

Enter in Item 22
Reg-Basis Code

Statutory Blindness

A61

                               

DC Claim and Claimant under Age 18—Denial

Basis for Decision

Enter in Item 22 Reg-Basis Code

No Visual Impairment1

Visual Impairment2

Engaging in SGA

N33

N33

Impairment(s) Disabling for a Period of Less Than 12 Months

N34

N45

Impairment(s) Disabling at Time of Adjudication But is Not Expected to be Disabling for a Period of 12 Months

N35

N46

Insufficient Evidence Furnished

N36

N36

Failure or Refusal to Submit to Consultative Examination and Insufficient Evidence

N37

N37

Applicant Does Not Want to Continue Development of Claim

N38

N38

Applicant Willfully Fails to Follow Prescribed Treatment

N393

N393

Impairment(s) Severe But Does Not Cause Marked and Severe Functional limitations; i.e., does not meet or medically or functionally equal the severity of a listing

N43

N43

Impairment Not Severe

N44

N44

1 Enter the applicable Reg-Basis Code from this column when the applicant does not allege a visual impairment.

2 Enter the applicable Reg-Basis Code from this column when the applicant alleges a visual impairment.

3 Also, use this code along with the appropriate DAA indicator, when DAA is material to the determination of disability.

                               DC Claim and Claimant under Age 18—Allowance

Basis for Decision

Enter In Item 22
Reg-Basis Code

Impairment Meets Level of Severity of Listings

A61

Impairment(s) Medically Equals Level of Severity of Listings

A65

Impairment(s) Functionally Equals Levels of Severity of Listings

A66

                                                    BC Claim-Allowance

Basis for Decision

Enter in Item 22

Reg-Basis Code

Statutory Blindness

A61

C. Description of Basis for Decision

1. Allowance

a. Impairment meets listings

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual is disabled on medical considerations alone because the disability is caused by an impairment specifically listed in the "Listing of Impairments" and the medical evidence contains the specific findings listed for the impairment. This entry will also include cases of “statutory blindness.”

No allowance should be coded as meeting the listings unless the specific medical criteria of one or more of the listed impairments are met, as shown by the medical evidence in file.

DIB, DWB, CDB Parent Determination DI, DS, AI, AS

DC age 18-21

DC under 18

BI/BS/BC

A1

A61

A61

A61

b. Impairment equals listings

Description of Basis for DecisionType of Claim

Reg. Basis Code1

The individual is disabled on medical considerations alone (or for DCs under 18, functional considerations as well) because of an impairment or a combination of impairments of severity equal to the level of severity contemplated in the "Listing of Impairments," but where all the specific requirements of the Listing are not met on the basis of the medical evidence in file.
No allowance should be coded as equaling the listings on the basis of medical evidence which is inadequate to describe impairment severity; the medical evidence should be adequate albeit somewhat different from the specific listing requirements.

DIB, DWB, CDB Parent Determination

DI/DS, AI, AS

DC Age 18-21

DC under 18 Medically Equals

DC Under 18 functionally equals

B1

A62

A65


A66

c. Severe impairment(s) short of the Listings plus adverse vocational factors

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual is disabled as defined in Regulation 404.1520(f) or 416.920(f) on the basis of a severe impairment(s) short of the severity in the “Listing of Impairments,” together with adverse vocational factors.

DIB, DWB, CDB Parent Determination

DI/DS, AI, AS

DC Age 18-21

C1

A63

d. 35-40 years of arduous unskilled work

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual with 35-40 years of arduous unskilled work and a marginal education who cannot work at the customary level of physical exertion because of a significant impairment(s) is disabled.

DIB, DWB Parent

Determination

DI/DS, AI, AS

D1

A64

2. Denial

a. Impairment prevents(ed) SGA (GA) for a period of less than 12 months

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The impairment is (or was) severe enough to prevent SGA (GA) at or after AOD but is not expected to (or did not) prevent SGA (GA) for a period of 12 months and is not expected to result in death.

DIB, CDB, DWB

Parent Determination

DI/DS, AI, AS

DC Age 18-21

E1, E2, E3 or E42 4

E1 or E32 4

N34 or N45

N35 or N464

b. Impairment(s) causes (or caused) marked and severe functional limitations for a period of less than 12 months

Description of Basis for DecisionType of Claim

Reg. Basis Code1

The impairment(s) did (or does) cause marked and severe functional limitations at or after AOD but is not expected to (or did not) cause marked and severe functional limitations for a period of 12 months and is not expected to result in death.

DC under 18

N34, N355

N45 or N465

c. Impairment not severe

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual is found not disabled on medical considerations alone because the impairment is not severe. The criteria of a non-severe impairment are met when the impairment(s) does not significantly limit the individual’s physical or mental capacity to perform basic work-related functions.

For DCs under age 18, the criteria of a nonsevere impairment are met when the impairment(s) does not cause more than a minimal limitation in the individual’s ability to function in an age -appropriate manner.

DIB, DWB, CDB

Parent Determination

DI/DS, AI, AS

DC Age 18-21

DC under 18

F1 or F2

F1

N30 or N41

N44

d. Child’s impairment(s) is not severe before age 22 or the end of the CDB re-entitlement period

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual is found to have a disabling impairment, but the condition was not disabling before age 22.

CDB

F1 or F2

e. Impairment(s) severe but does not cause marked and severe functional limitations; i.e., does not meet or medically or functionally equal the severity of a listing

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The impairment is severe but not disabling because it does not cause marked and severe functional limitations (i.e. it does not meet or medically or functionally equal the severity of a listing.

DC under 18

N43

f. Capacity for SGA (CDB case)

Description of Basis for Decision

Type of claim

Reg. Basis Code1

The child has a severe impairment(s) but is found not disabled because he or she has a functional and vocational capacity to engage in substantial gainful activity.

CDB

G1 or G2

g. Capacity for SGA—relevant past work

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual has a severe impairment(s) but is found not disabled because he or she has the functional and vocational capacity to engage in substantial gainful activity in relevant past work.

DIB, DWB

Parent Determination

DI/DS,AI, AS and DC Age 18-21

H1 or H2)

H1

N31 or 42

h. Capacity for SGA—other than relevant past work

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual has a severe impairment(s) but is found not disabled because he or she has the functional and vocational capacity to engage in substantial gainful activity in other than relevant past work for which he or she is capable by past education, training or work experience.

DIB, DWB

Parent Determination

DI/DS,AI,AS and DC Age 18-21

DC Under 18

J1 or J2

J1

N32 or N43

i. Failure to follow prescribed treatment

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual willfully, without justifiable cause, fails to follow therapy prescribed by the treatment source for a disabling impairment which is amenable to treatment that could be expected to restore ability to work, or, if a DC under 18, to function in an age - appropriate manner.

DIB, CDB, DWB

Parent Determination

DI/DS, AI, AS and DC Age 18-21

DC Under 18

K1 or K2

K1

N396

j. Refusal or failure to appear for a consultative examination

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual refuses or fails to present him or herself for a consultative examination which is considered essential to a proper determination and there is insufficient evidence in file to make a determination

DIB, CDB, DWB

Parent Determination

DI/DS, AI, AS and DC Age 18-21

DC Under 18

L1 or L2
L1

N37

k. Failure to cooperate in submitting evidence of disability

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

The individual is found not disabled because of failure to cooperate in submitting medical, functional, or vocational evidence necessary for a determination.

DIB, CDB, DWB

Parent Determination

DI/DS, AI, AS and DC Age 18-21

DC Under 18

M5 or M63

M5

N36

l. Does not wish to continue development of claim

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

1) Wants Decision Made on Evidence in File—The individual does not wish to continue development of the claim, wants a decision made on the evidence in file and the evidence does not establish that the individual is disabled.

DIB, CDB, DWB

Parent Determination

DI/DS, AI, AS and DC Age 18-21 DC Under 18

M3 or M4

M3

N38

2) Does Not Indicate Decision to be Made on Evidence in File—The individual does not wish to continue development of the claim, does not indicate that he/she wants a decision to be made on the evidence in file and the evidence does not establish that the individual is disabled.

DIB, DWB

CDB

Parent Determination

DI/DS, AI, AS and DC Age 18-21, DC Under 18

M7 or M8

M3 or M4

M3

N38

m. SGA

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

Engaging in SGA—The individual is found not disabled because he /she is engaging in substantial gainful activity.

DIB, DWB

DI/DS, AI, AS and DC Age 18-21

N1 or N2

N33

n. DAA

Description of Basis for Decision

Type of Claim

Reg. Basis Code1

Drug addiction and/or Alcoholism is material to the determination of disability

DIB, DWB, CDB

Z1 or Z2

1 The numerical codes "1," "3," "5" and "7" (e.g., "A1" or "E3") signify that the earnings requirement (in DIB cases) or the prescribed period requirement (in DWB and CDB re-entitlement cases) is not at issue. The numerical codes "2," "4," "6" and "8" indicate that in addition to the basis for the disability determination, the earnings requirement, prescribed period requirement, or re-entitlement period requirement expired before the date of the current decision; e.g., claimant is not disabled through the date the earnings requirement was last met.

2 These codes are used to differentiate between an impairment that prevents SGA at time of adjudication but is not expected to prevent SGA for 12 months as opposed to an impairment that no longer prevented SGA at time of adjudication and did not prevent SGA for 12 months.

3 Do not use M6 when the claimant cooperated but there is insufficient evidence of a disability relating to the period before the insured status or prescribed period requirement was last met. In these situations, use F2.

4 These codes are used to differentiate between an impairment that results in marked and severe functional limitations at time of adjudication but is not expected to do so for 12 months (N35, N46), as opposed to an impairment that no longer causes marked and severe functional limitations at time of adjudication and did not do so for 12 months (N34, N45).

5 Also use this code along with the appropriate DAA indicator when DAA is material to the determination of disability.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0426510045
DI 26510.045 - Completing Item 22 (Regulation Basis Code) on the SSA-831 - 03/14/2016
Batch run: 03/14/2016
Rev:03/14/2016