Identification Number:
DI 22510 TN 20
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 225 – Case Development Procedures
Subchapter 10 – Development of Consultative Examinations (CE)
Transmittal No. 20, 01/10/2020

Audience

PSC: DE, DEC;
OCO-OEIO: CR, ERE, FCR, FDE, RECONE;
OCO-ODO: DE, DEC, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

01/06/2020

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure,

Summary of Changes

DI 22510.001 Introduction to Consultative Examinations (CE)

We changed the wording and reference in DI 22510.001D.5 for consistency with the revised FTC policy .

DI 22510.010 Selecting a Qualified Medical Source to Perform a Consultative Examination (CE)

We revised the sentence, updated the references, and removed the examples of claimants who require special handling and replaced it with a reference to the revised special handling categories in DI 22510.010E for consistency with the revised FTC policy.

DI 22510.001 Introduction to Consultative Examinations (CE)

CITATIONS:

20 CFR sections

A. Definitions for CE policy

1. Consultative examination (CE)

A CE is a physical or mental examination or test purchased from a medical source, at the Social Security Administration's request and expense, to provide evidence for a claimant’s disability or blindness claim.

2. Evidence

Evidence is anything relevant to a claim that the claimant or anyone else submits or that we obtain. For a detailed explanation of evidence, see DI 22501.001B.

3. Medical source

For the definition of medical source, see DI 22505.001A.4.

  • Acceptable medical source, or

  • Other health care provider who is not an acceptable medical source.

4. Claimant’s own medical source

A claimant’s own medical source is a medical source who has provided a claimant with evaluation, examination, or treatment.

  • Provides or has provided the person with medical treatment or evaluation, and

  • Has or has had an ongoing treatment relationship with the person.

5. Qualified CE source

A qualified CE source is a medical source who:

  • Is currently licensed (or certified in the case of a psychologist, or otherwise qualified in the case of a speech-language pathologist) in the State in which he or she performs the CE.

  • Has the training and experience to perform the type of examination or test requested; and

  • Is not barred from participation in Medicare or Medicaid programs or any other Federal or federally assisted programs.

For policy on selecting a qualified medical source for a CE and on the qualifications required of support staff assisting a qualified source in performing a CE, see DI 22510.010.

For details about CE source licensure, see DI 39569.300.

For details about program integrity considerations, see DI 39569.200A.

B. Policy for approval of CEs

Some Disability Determination Services (DDS) may require supervisory approval for the authorization or purchase of CEs. Follow your DDS business process regarding supervisory approval.

If the CE could involve significant risk to the claimant, see additional approval requirements in DI 22510.006C.

C. Policy for payment for CEs

  • We pay for any CE we order for the claimant.

  • We do not pay for any medical examination arranged by the claimant or the claimant's representative, unless we approve it in advance.

D. Procedures for ordering a CE

  1. 1. 

    Make the decision to purchase a CE on an individual case basis.

  2. 2. 

    Purchase only the specific test or examination needed. For example, if you need only an x-ray, EKG, or blood test, do not authorize a comprehensive medical examination.

  3. 3. 

    Select an appropriate CE source. (See DI 22510.010.)

  4. 4. 

    Notify the CE source in writing. (See DI 22510.017A.)

  5. 5. 

    Provide the CE source collateral evidence, if appropriate. (See DI 22510.017B.)

  6. 6. 

    If ordering a CE for a case pending hearing, see additional instructions in DI 29501.010.

DI 22510.010 Selecting a Qualified Medical Source to Perform a Consultative Examination (CE)

Citations: 20 CFR sections 404.1503a,404.1519, 404.1519g through 404.1519i, 416.903a, 416.919, 416.919g through 416.919i

A. Qualifications of the CE source and support staff

Purchase a CE only from a medical source who is a qualified CE source as defined in DI 22510.001A.5. A qualified CE source may use support staff (for example, an x-ray technician or a registered nurse) to help perform the CE.

Support staff who help with the CE must:

  • Meet the licensing or certification requirements of the state in which the CE is performed; and

  • Not be currently excluded, suspended, or otherwise barred from participation in Medicare or Medicaid programs or any other Federal or federally assisted programs.

For information on monitoring support staff qualifications, see DI 39569.300C.

B. Program integrity

The Disability Determination Services (DDS) is responsible for CE process integrity.

For details see:

  • DI 39569.100 Conflict of Interest

  • DI 39569.200 The Social Security Administration (SSA) Program Integrity Standards

  • DI 39569.300 Disability Determination Services Requirements for Ensuring Proper Licensures, Credentials, and Exclusions of Consultative Examination (CE) Providers, CE Provider’s Employees, Medical and Psychological Consultants (MC/PC)

C. Choose the appropriate CE source based on the information needed

The CE source must have the training and experience needed to perform the examination(s) and test(s) requested.

1. Need for a specialist

Generally, a qualified CE source does not have to be a specialist in the medical field relevant to the claimant’s impairment(s) to perform a CE. For example, a qualified internist may perform a CE involving impairments of the musculoskeletal, cardiovascular, neurological, and other body systems.

If you need a specialist examination or test because of the nature or complexity of a particular impairment(s), select the appropriate specialist to perform the CE, if available.

Use a claimant’s own medical source to perform the CE only if he or she:

  • Has the specialist qualifications, as explained in DI 22510.010D.1. in this section;

  • Is willing to perform the CE; and

  • Is otherwise qualified to be a CE source, as defined in DI 22510.001A.5.

2. Need for acceptable medical source

a. When the CE source must be an acceptable medical source (AMS)

If a purpose of the CE is to obtain objective medical evidence you need to establish the existence of a medically determinable impairment (MDI), the qualified CE source must be an AMS.

NOTE: Some medical sources are AMSs only for claims with a filing date on or after March 27, 2017. For more information, see DI 22505.003 Evidence from an Acceptable Medical Source (AMS).

b. When the qualified CE source may be a medical source who is not an AMS

If objective medical evidence from an AMS already establishes the existence of the MDI, authorize purchase of a CE from a qualified CE source who is not an AMS to document the severity of the impairment and its effect on the claimant’s functioning.

Example 1 (physical impairment): Evidence from an AMS establishes the existence of a musculoskeletal MDI. However, you need more information about the current severity of the impairment. A qualified physical therapist may perform the CE required to show the severity of the impairment and its effect on the claimant’s functioning.

Example 2 (mental impairment): Evidence from an AMS establishes the existence of a mental MDI. However, you need more information about the severity and functional effects of the mental impairment. You may obtain a CE from a qualified licensed clinical social worker to document the severity and functional effects of the mental impairment.

c. More than one source

It may be appropriate to send the claimant to his or her own medical source for an examination and to another medical source for a specific test, such as a blood test, electrocardiogram, or intelligence quotient test.

D. Claimant’s own medical source may be a preferred CE source

Consider whether to obtain a CE from the claimant’s own medical source.

1. When to obtain a CE from the claimant’s own medical source(s)

The claimant’s own medical source(s) is generally the preferred CE source. Schedule a CE with one of the claimant’s medical sources if the claimant has a medical source who:

  • Is a qualified CE source;

  • Has adequate training and experience necessary to perform the types of examinations and tests needed;

  • Has access to the equipment required to perform the types of examinations and tests needed;

  • Is willing to perform the examination or test for the fee schedule payment, as explained in DI 39545.600; and

  • Is willing to provide a detailed written report of the examination in a timely manner (generally a week to 10 days from the date of the examination).

EXCEPTION: If a claimant’s own medical source failed or refused to provide available medical evidence when you made every reasonable effort to obtain the evidence from this source, do not schedule a CE with this source.

2. Procedure to determine a medical source’s willingness to perform a CE

Determine whether a medical source is willing to perform a CE using any of the following methods:

  • A general survey of medical sources in the State once every three years;

  • An inquiry on the medical evidence of record (MER) request letter sent to the medical sources; or

  • A telephone call to the medical source when you decide that you need a CE.

NOTE: 

Assume that a medical source who fails to respond to a survey or a request in the MER letter is not interested in performing a CE.

3. Schedule a CE with a qualified CE source who is not the claimant’s medical source

Schedule a CE with a qualified source who is not the claimant’s own medical source under any of the following circumstances:

  • The source(s) is unwilling or unqualified to perform the CE;

  • The claimant has no medical sources that meet the criteria in DI 22510.010D.1. in this section;

  • The claimant’s own medical source(s) did not provide available medical evidence that you made every reasonable effort to obtain;

  • There are conflicts or inconsistencies in file that you cannot resolve by going back to the claimant’s own medical source(s);

  • The claimant has good reason to object to obtaining a CE from his or her own medical sources, as explained in DI 22510.010E in this section; or

  • You have reason to question the quality or objectivity of the medical source or the quality of the source’s evidence.

    For example:

    Case circumstances (e.g., evidence that the medical source has a personal relationship with the claimant) cast doubt on the medical source’s objectivity, the medical source’s findings are virtually identical to those reported by the same medical source for other claimants, or the case record suggests the claimant was feigning disability or coaching was involved. If any of these circumstances apply, consider whether there is an issue of fraud or similar fault (see DI 23025.005).

Always document the reason you did not use the claimant’s own medical source(s) in eCAT on the CE screen or on the case development summary worksheet. In paper claims, document the reason on the case development summary worksheet.

E. Claimant may object to the selected CE source

If the claimant, applicant or appointed representative objects to the selected CE source, consider rescheduling the CE if there is a good reason for the objection.

1. Policy to reschedule appointments based on claimant objection to the CE source

If the claimant (or the claimant’s appointed representative, or an applicant in a childhood disability claim) objects to the medical source designated to perform the CE, and has a good reason for the objection, schedule the CE with another medical source and document the objection in the file for future reviewers. If the claimant does not have a good reason for the objection and refuses to attend the CE, see DI 23007.015.

2. Good reasons for objection to a CE source

Good reasons for objection to a CE source include but are not limited to:

  • The CE source represented the claimant's employer in a workers' compensation case;

  • The CE source was involved in an insurance claim or legal action adverse to the claimant;

  • The CE source examined the claimant in connection with a previous disability determination or decision that was unfavorable to the claimant; and

  • The CE source's office location does not have needed disability access features (e.g., an elevator).

NOTE: 

If the claimant requires special handling, follow procedures in DI 22510.016D.2. For claimants who require special handling, see DI 23007.001A.

3. Procedure when a claimant or an appointed representative alleges the CE source lacks objectivity

If a claimant or appointed representative alleges the CE source may not be objective, review the allegation and take the following action:

  • If a prior review of the CE source found that the source’s reports conform to the guidelines in DI 22510.020, do not change the claimant’s appointment.

  • If there is no prior review, schedule the CE with another qualified CE source and investigate the allegation to avoid delay in processing the case.

  • Notify the claimant (the claimant’s appointed representative or an applicant in a childhood disability claim) whether you will or will not change the CE source for the examination.

  • Document the case file with all actions taken and the reasons for the actions.


DI 22510 TN 20 - Development of Consultative Examinations (CE) - 1/06/2020