Effective Dates: 3/28/2024 - Present

Identification Number:
DI 22510 TN 39
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Full 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. 39, 03/28/2024

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

Upon Receipt

Background

The Office of Disability Policy is updating these sections for consistency with the publication of the new Program Operations Manual System (POMS) sections DI 22510.013 and DI 22510.014 related to Telehealth Consultative Examinations (THCE).

Summary of Changes

DI 22510.001 Introduction to Consultative Examinations (CE)

We updated this POMS to:

  • •

    Define THCE and clarify that a claimant uses a personal device from their home or private location;

  • •

    Define Video Consultative Examination (VCE) and clarify that a claimant uses equipment at a location provided by Social Security Administration (SSA) or Disability Determination Services (DDS);

  • •

    Change the title of subsection B. to "Supervisory approval for CEs"; and

  • •

    Change the title of subsection C. to "Payment for CEs."

DI 22510.015 Information for Consultative Examination (CE) Source

We updated this POMS section to:

  • •

    Clarify CE scheduling intervals in subsection A.1;

  • •

    Remove subsections A.2 and A.4;

  • •

    Move subsection A.3 to subsection B.1;

  • •

    Clarify the preferred methods of CE report submission with cross reference to DI 81020.060;

  • •

    Add information about THCEs to subsection B.2;

  • •

    Clarify in subsection B.3 that a Medical Opinion (MO) is an element of a complete CE report and should be included as part of the CE process, but the absence of an MO in a CE report does not always make the CE report incomplete; and

  • •

    Clarify in subsection B.3 that DDS should follow up for an MO if the CE report is incomplete without it.

DI 22510.001 Introduction to Consultative Examinations

CITATIONS:

20 CFR sections
404.1517, 404.1519 through 404.1519t, 416.917, and 416.919 through 416.919t .

A. Definitions

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 (SSA) request and expense, to provide evidence for a claimant’s disability or blindness claim. In addition to in-person CEs, SSA offers telehealth and video CEs in some circumstances.

a. Telehealth consultative examination (THCE)

A THCE is a CE that:

  • •

    Uses audio and video technology to allow remote interaction between a CE source and a claimant or beneficiary;

  • •

    Requires the claimant or beneficiary to participate using a personal device at their home or other private location; and

  • •

    Requires the claimant or beneficiary to participate using a platform selected by the CE source.

For detailed information about THCEs, see DI 22510.013.

b. Video consultative examination (VCE)

A VCE is a CE that:

  • •

    Uses audio and video technology to allow remote interaction between a CE source and a claimant or beneficiary;

  • •

    Requires the claimant or beneficiary to participate using equipment at a location provided by SSA or the Disability Determination Services (DDS); and

  • •

    Requires the claimant or beneficiary and the CE source to access the connection using a platform selected by SSA or DDS.

For detailed information on VCEs, see DI 22510.012.

2. Medical source

A medical source is an individual who is either:

  • •

    Licensed as a healthcare worker by a state and working within the scope of practice permitted under State or Federal law, or

  • •

    Certified by a State as a speech-language pathologist or a school psychologist and acting within the scope of practice permitted under State or Federal law.

a. Acceptable medical source (AMS)

An AMS is a medical source who may provide evidence we use to establish the existence of a medically determinable impairment (MDI). For detailed information about acceptable medical sources, see DI 22505.003.

b. Claimant's own medical source

A claimant's own medical source is a medical source who:

  • •

    Provides or has provided the claimant with evaluation, examination, or treatment; and

  • •

    Has or has had an ongoing treatment relationship with the claimant.

c. CE source

A CE source is a medical source who performs a CE. SSA only uses qualified CE sources to perform CEs.

d. 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 they perform 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.

A qualified medical source may also be an AMS or the claimant's own medical source.

For information on:

  • •

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

  • •

    When to obtain a CE from the claimant's own medical source, see DI 22510.010D.

  • •

    CE source licensure, see DI 39569.300.

  • •

    Program integrity considerations, see DI 39569.200A.

B. Supervisory approval for CEs

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 DI 22510.006C.

C. Payment for CEs

  • •

    SSA pays for any CE ordered for the claimant; and

  • •

    SSA does not pay for any medical examination arranged by the claimant or the claimant's appointed representative unless it is approved in advance.

For more information on purchasing CEs, see DI 39545.000.

D. Procedures for ordering a CE

  1. 1. 

    Make the decision to purchase a CE on an individual case basis and consistent with instructions in DI 22510.005 and DI 22510.006.

  2. 2. 

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

  3. 3. 

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

  4. 4. 

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

  5. 5. 

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

DI 22510.015 Information for Consultative Examination Source

CITATIONS:

20 CFR
401.100 et seq., 404.1519n, 404.1519o, 416.919n, 416.919o.

A. Information to provide to consultative examination (CE) sources

Medical sources who perform CEs need information that provides a good explanation of the Social Security disability programs and the relevant evidentiary requirements.

For the definitions of CE sources, see DI 22510.001A.

Provide the following information to all new CE sources and periodic reminders to all existing CE sources. For more information on CE source training, see DI 39545.400B.

1. CE scheduling information

CE appointments must allow sufficient time for the CE source to take a case history, when appropriate, and to perform the requested type of examination. For information on minimum scheduling intervals, see DI 39545.250A. The Disability Determination Services (DDS) will use discretion when scheduling and allow more time for an examination when past experience necessitates more time for a certain source or type of examination.

2. CE report content

Follow policy for CE report content, including guidelines that apply to all CEs (DI 22510.015B in this section) and guidelines that apply to certain examinations only (DI 22510.035 through DI 22510.060 for children and DI 22510.100 through DI 22510.114 for adults).

3. CE report submission

Explain when and how the source will submit the CE report. Preferred methods for CE report submission are Electronic Records Express (ERE), fax, or other Social Security Administration (SSA) approved secure electronic communication methods. For more information about receiving evidence, see DI 81020.060.

4. Rates of payment

Advise the CE source of the established rates of payment (fee schedules) and customary procedures for fee authorization.

See details:

5. Privacy Act information

Explain that CE reports developed on behalf of the agency are subject to SSA's privacy regulations at 20 C.F.R. Part 401. Explain that these regulations:

  • •

    Govern both the agency's and CE source's use of the examination report (including background material furnished to the source);

  • •

    Strictly prohibits unauthorized disclosure of claimant information and subjects unauthorized disclosure to legal penalties; and

  • •

    Gives the claimant access rights to records we maintain about them. Therefore, we cannot guarantee the CE source confidentiality.

For more information on CE source confidentiality requirement, see DI 39518.045.

6. CE source required referrals

Explain that the CE source must contact the DDS immediately when:

  • •

    Anyone, including the claimant, requests a copy of the CE report or associated records; see GN 03300.000.

  • •

    The CE source is subject to a court order, subpoena, or other request concerning disclosure of information about or testimony related to the source’s CE or CE records. Instruct the CE source that they must provide the DDS with a copy of the court order, subpoena, or other request either by fax or by email. Explain to the CE source that they must wait for instruction from the DDS before releasing records or disclosing information in response to a court order, subpoena, or other request.

NOTE: If the CE source notifies the DDS of a court order, subpoena, or other request, contact the Associate Regional Commissioner for Management and Operations Support for case-specific instructions. See details in GN 03330.010.

B. CE report requirements

To provide reliable evidence, a CE report must reflect accepted professional medical standards and practice. When less than a complete CE report is needed (e.g., only a specific laboratory test result to complete the file is needed), every element listed in this section may not be necessary.

The detail and format for reporting the results of a CE will vary, depending on the type of examination or testing requested. Provide the CE source case-specific CE report requirements in writing. For details, see DI 22510.017A.

1. Claimant identification

The CE report must include:

  • •

    Documentation that the claimant provided proof of identity by showing a valid and current government photo identification (ID) (e.g., United States (U.S.) State-issued driver's license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.), or

  • •

    A physical description of the claimant, to help ensure that the CE source examines the claimant, unless the CE source is the claimant's own medical source.

For more information on:

  • •

    CE providers verifying ID when conducting the CE, see DI 39542.235.

  • •

    ID requirements for telehealth consultative examinations (THCE), see DI 22510.013D.3.

2. Medical elements of a complete CE report

The medical report must include the following elements:

  • •

    The claimant’s major or chief complaint(s) and any other abnormalities, or lack thereof, reported or found during the examination or laboratory testing. The report must include the claimant’s own statement of symptoms in addition to the CE source’s statements or conclusions.

  • •

    A detailed description, within the area of specialty of the examination, of the history of the major complaint(s).

  • •

    A detailed description and disposition of pertinent “positive” and “negative” objective findings based on the history, examination, and laboratory tests related to the major complaint(s) and any other abnormalities, or lack thereof, reported or found during examination or laboratory testing.

  • •

    The results of laboratory and other tests (e.g., x-rays) performed in accordance with the requirements stated in the Listing of Impairments.

  • •

    Diagnosis and prognosis.

  • •

    A medical opinion (MO) from the CE source expressing an opinion about what the claimant can still do despite their impairment(s).

  • •

    For THCEs, a statement that the CE was conducted via telehealth and the name of the video application used.

  • •

    For video consultative examinations (VCE), a statement that the CE was conducted via video teleconferencing.

IMPORTANT: A complete CE report involves all the elements of a standard examination in the applicable medical specialty. The report must be complete enough to show the nature, severity, and duration of the claimant's impairment(s), and the claimant's ability to function. For detailed CE report content guidelines about each body system:

3. Medical Opinions (MO) from CE sources

An MO is a statement from a medical source about what the claimant can still do despite their impairment(s) and whether they have one or more impairment-related limitations or restrictions in certain work-related activities. In Title XVI child claims, an MO is about the child’s ability to function. The MO is an element of a complete CE report and should be included as part of the CE process. However, the absence of an MO does not always make a CE report incomplete. The report must be complete enough to enable an independent reviewer to determine the nature, severity and duration of the impairment(s) and, in adult claims, the claimant’s ability to perform basic work-related functions. For instructions about when a CE report is inadequate, see DI 22510.020B.3.

a. Requesting an MO

Request the CE source provide an MO that addresses functional abilities relevant to the CE and the claim.

b. When not to request an MO

Do not request an MO:

  • •

    In statutory blindness claims, or

  • •

    When the claimant is sent to a laboratory to only have objective testing (e.g., a blood test).

c. When to follow up on an MO

If the CE report is missing an MO and the DDS has determined the report is incomplete without the MO, recontact the CE provider to provide an MO.

C. CE report signature policy

The medical source who actually performed the examination must personally review and sign all CE reports.

The CE source signature attests that the source is solely responsible for the report contents and for the conclusions, explanations, or comments provided with respect to the history, examination, and evaluation of laboratory test results.

For additional information about CE report signatures, see DI 81020.070.

1. Acceptable CE report signatures are:

  • •

    Original handwritten signatures, signed in ink, on the original paper copy of the CE report;

  • •

    eFax or analog fax of the CE report with the original handwritten signature(s); or

  • •

    Electronic signatures applied in and submitted through the ERE process.

IMPORTANT: ERE is the only electronic signature technology approved by the agency for obtaining policy-compliant CE report signatures. Only users registered with ERE as a CE source will have the electronic signature option. If more than one signature is required on the CE report as noted in DI 24583.050B.2, ERE cannot be used to apply the signature and eFax or analog fax should be used to submit the CE report with the original handwritten signatures.

2. Reviewing CE report signatures for acceptability

For an explanation of how to adjudicate a claim with an unsigned or improperly signed CE report in file, see DI 22510.020C.

3. Reviewing CE reports for acceptable electronic signatures

Registered CE sources submit electronically signed copies of CE reports using the ERE “click and sign” feature. This produces a signature that is electronically linked to, and included with, the CE report in the certified electronic folder (CEF). The ERE CE certification language reads:

“I am certifying, under penalty of perjury, that I have been authorized or contracted by the Disability Determination Services to examine the claimant named in the attached, and produced a consultative examination report for that claimant. The report is accurate. By checking the “I have read and agreed with the above” check box below, I am certifying that I personally conducted, or personally participated in conducting, the consultative examination and have electronically signed the report contained within.”

NOTE: For paper folders, the CE report must contain a printout of the ERE CE certification language along with the ERE signature. The ERE signature shows the printed name of the signer or the signer’s personal identification number (PIN)/user name, and the month, day, and year of the signature.

IMPORTANT: A signature produced by a CE source’s own electronic record keeping system does not meet our requirements for an acceptable CE report signature.

4. Reviewing CE reports for acceptable non-electronic CE report signatures

The CE source's signature as noted in DI 22510.015C.1 in this section, must appear on the copy of the CE report in the disability folder.

A CE report is considered unsigned or improperly signed if it contains:

  • •

    An annotation of “not proofed” or “dictated but not read”;

  • •

    A rubber-stamped signature of a medical source; or

  • •

    The CE source's signature entered by any other person.

DI 22510 TN 39 - Development of Consultative Examinations (CE) - 3/28/2024