TN 37 (11-23)

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 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, 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).

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510044
DI 22510.044 - Pediatric Consultative Examination (CE) Report Content Guidelines for Skin Disorders - 11/02/2023
Batch run: 11/02/2023
Rev:11/02/2023