TN 22 (09-20)

DI 22510.101 Adult Consultative Examination (CE) Report Content Guidelines for Musculoskeletal Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with musculoskeletal disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for adult musculoskeletal disorders

The CE report guidelines for adult musculoskeletal disorders in this section are in addition to the general CE report content guidelines in DI 22510.100.

B. Report content specific to musculoskeletal disorders

The CE provider will use the specific requirements below to complete the CE report for a musculoskeletal disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Character, location, and radiation of pain;

  2. b. 

    Factors that incite and relieve the pain as well as attempted treatment modalities such as medication, physical therapy, and/or surgical intervention, as well as their effect;

  3. c. 

    Any history of fractures of bones (traumatic), dates and frequency of fractures, imaging (if available), and the status of any fractures (including clinical evidence of union or non-union) at the time of the examination;

  4. d. 

    Symptoms of weakness, other motor loss, and/or any sensory abnormalities; and

  5. e. 

    Dates and results of any relevant diagnostic procedures, such as x-rays, myelography, CT scan, MRI, and radio-nuclear bone scan.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Any apparent abnormalities such as gait or the need for any type of assistive device:

1. If the claimant uses an assistive device(s), note the type of, and medical need for, the device, the medical impairment the device is needed for, and examination findings that support the medical need for the assistive device. Also, 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. For lower extremity assistive devices, describe the claimant’s gait with and without use of the device.

3. Describe the claimant's ability to bend, squat, arise from a squatting position, tandem walk, walk on their heels and toes, get up from a chair, get on and off the examining table, and dress and undress.

b. Extremities and peripheral joints:

1. Active and passive range of motion. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;

2. Effusion;

3. Periarticular swelling;

4. Pain, if any, and its distribution;

5. Tenderness;

6. Redness or heat;

7. Thickening;

8. Structural deformities;

9. Instability;

10. Grip, pinch, ability to close the fist or perform fine and gross manipulations, and strength (measured either by dynamometer or 0-5 scale);

11. Extremity strength (measured either by dynamometer or 0-5 scale);

12. Atrophy; and

13. Ability to use, and effective use of, any orthoses.

c. Spine:

1. Distribution of pain, tenderness, and sensory and/or motor loss;

2. Muscle spasms, when present;

3. Intensity and symmetry of deep tendon reflexes;

4. Active range of spinal motion;

5. When the lumbar spine is an issue, straight-leg raising (lumbar spine, both sitting and supine); and

6. When the cervical spine is an issue, provocation test for radiculopathy, such as the Spurling Test (cervical spine).

d. Amputated extremities:

1. Description of stump, including integrity of skin flap;

2. Tenderness; and

3. Ability to use, and effective use of any prostheses, as well as the functional level of the contralateral extremity. It is not necessary to evaluate the individual’s ability to walk without the prostheses in place.

e. Fractures of bones of extremities or pelvis:

1. Review of imaging such as x-rays or MRI; and

2. Clinical evidence of union or non-union.

f. Soft tissue injuries/burns:

1. Nature and extent of the injury;

2. Skin sensitivity; and

3. Effect the injury has on joint motion.

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DI 22510.101 - Adult Consultative Examination (CE) Report Content Guidelines for Musculoskeletal Disorders - 09/25/2020
Batch run: 09/25/2020