Effective Dates: 10/06/2023 - Present

Identification Number:
DI 22510 TN 34
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. 34, 10/06/2023

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

10/06/2023

Background

This transmittal updates the Program Operations Manual System (POMS) sections relating to the Digestive and Skin Final Rule.

Summary of Changes

DI 22510.044 Pediatric Consultative Examination (CE) Report Content Guidelines for Skin Disorders

We updated Pediatric Consultative Examination Report guidelines for skin disorders based on the new skin listings.

Updated formatting and grammar as needed throughout the document.

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

We updated Adult Consultative Examination Report guidelines for skin disorders based on the new skin listings.

DI 22510.044 Pediatric Consultative Examination (CE) Report Content Guidelines for Skin Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

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

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric 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:

  1. a. 

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

  2. b. 

    Results of relevant diagnostic procedures;

  3. c. 

    Treatment modalities, dates of treatments, and responses to treatments;

  4. d. 

    Frequency, severity, and duration of skin lesion exacerbations;

  5. e. 

    Effects on age-appropriate activity, especially social behavior, because of disfigurement; and

  6. f. 

    If the claimant uses a lower extremity assistive device, note whether the assistive device was prescribed, how frequently it is used, the date is was prescribed, and the medical source who prescribed it.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Location, size, and appearance of skin lesion(s) and contractures, associated symptoms such as pain or tenderness, and extent of the body affected (e.g., one or both extremities);

  2. b. 

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

  3. c. 

    If at least one extremity is affected (including involvement of the perineum or inguinal region affecting lower extremity functioning), describe ability to:

    1. 1. 

      Perform age-appropriate gross (e.g., reaching, lifting, carrying, handling, and gripping) and fine (e.g., picking, pinching, manipulating, and fingering) movements ;

    2. 2. 

      Stand up from a seated position; and

    3. 3. 

      Maintain an upright position while standing or walking.

  4. d. 

    Provide a description of the claimant’s gait. If the claimant uses a lower extremity assistive device, describe:

    1. 1. 

      Claimant’s gait with and without use of the device; and

    2. 2. 

      The device and how it is used by the claimant, the medical need for the device, the medical impairment the device is needed for, and the examination findings that support the medical need for the assistive device; and

  5. e. 

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

 

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:

  1. a. 

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

  2. b. 

    Treatment modalities, dates of treatments, and responses to treatments;

  3. c. 

    Frequency, severity, and duration of skin lesion exacerbations; and

  4. d. 

    If the claimant uses a lower extremity assistive device, note whether the assistive device was prescribed, how frequently it is used, the date it was prescribed, and the medical source who prescribed it.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Location and size of skin lesion(s) and contractures, associated symptoms such as pain or tenderness, and extent of the body affected (e.g., one or both extremities);

  2. b. 

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

  3. c. 

    If at least one extremity is affected (including involvement of the perineum or inguinal region affecting lower extremity functioning), describe ability to:

    1. 1. 

      Perform gross (e.g., reaching, lifting, carrying, handling, and gripping) and fine (e.g., picking, pinching, manipulating, and fingering) movements;

    2. 2. 

      Stand up from a seated position; and

    3. 3. 

      Maintain an upright position while standing or walking.

  4. d. 

    Provide a description of the claimant’s gait. If the claimant uses a lower extremity assistive device, describe:

    1. 1. 

      Claimant’s gait with and without use of the device; and

    2. 2. 

      The device and how it is used by the claimant, the medical need for the device, the medical impairment the device is needed for, and the examination findings that support the medical need for the assistive device; and

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

DI 22510 TN 34 - Development of Consultative Examinations (CE) - 10/06/2023