July 29, 2014

The Consultative Exam (CE): Part 3

Hello and welcome to the final installment of my 3-part mini-series on the Social Security Disability consultative examination (CE).  Part 1 is here and Part 2 is here.  In this final post, I discuss what can you can expect at a CE and what kind of information that the CE will need to contain to substantiate your disability claim.

Question:

What type of information does the CE (consultative examination) need to contain in order to substantiate my claim for disability?

Answer:

The CE is more or less a doctor’s appointment in which (typically) an independent medical examiner will conduct additional medical testing or assessment in order to help make your disability case file complete so that the SSA may be able to render a decision in your claim.What happens at the CE depends on what kind of testing (psychological, neurological, and so on) is required by the SSA. But since you have probably already had plenty of experience with doctors by this time, the CE shouldn’t necessarily hold any surprises.

In terms of information needed in the actual examination report, the following guideline is a comprehensive list of information needed to ensure that your claim is further processed without additional delay:

A physical description of the claimant; this is an additional tool to ensure that the medical records are those of the claimant and not those of another individual.

All medical history, physical examination, laboratory findings and diagnoses should be included. The report should be such that an independent reviewer is able to determine the nature, severity and duration of the impairment as well as the claimant’s ability to perform basic functions required in the simplest of jobs without requiring additional information. If the report is incomplete, the examiner will be contacted and a request to supplement the records and/or clarify will be made thus creating additional delay.

Include a narrative finding in the history and of the physical examination.

Conclusions following the CE must be consistent with all other medical documentation under consideration.

The report should not include an opinion as to whether the claimant is disabled under the law.

All CE reports must be reviewed and signed by the provider who performed the examination.

Well, I hope this covers everything you need to know about the CE. Feel free to share stories about your CE or ask additional questions about the consultative exam by leaving a comment below.

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Jonathan Ginsberg represents Social Security disability claimants in Georgia. In practice for over 23 years, Jonathan publishes a widely known disability blog, a podcast and several disability web sites. In 2004, Jonathan published a "how to" book about Social Security disability called the Disability Answer Guide. Jonathan lives with his wife and 2 children in Atlanta.

Comments

  1. This information was helpful for me as I am fairly new in my field as a Disability Benefit Specialist. I have had the opportunity to review 2 case files for clients I am assisting appeal a SSA decision. In both cases for the intial application the CE performing the evaluation noted “I review one page of medical history and one page of another document, spent 40 minutes with the claimant”. In both cases the CE assured the claimants that there should be no problems and they would receive a approval. Yet the CE found both not meeting the requirements. I wonder how much of the previous file information the CE is required to review.

  2. s a gilbert says:

    i’m confused. the only reason i’m here is to find out what i can expect from the ce! why would you assume that i already have plenty of experience with doctors? if i had the money to pay a doctor’s bill why would i need ssd? i don’t understand any of the crap associated with qualifying for this! i’m getting the feeling that without an attorney, i don’t stand a chance! why are they going to make it so difficult for me to get the money that came 100% from me anyway?! i’m sorry for probably being naive but i’m an honest person that has never tried to get money from any other way but working for it. i’m having a hard enough time accepting that i can’t do the kind of work that i love doing! it won’t take much for them to convince me that i don’t qualify because i want to believe more than anyone… that i don’t!!! i’m gonna be homeless (and by all accounts, i should be already) because they deny everybody that can get out of bed almost every day! i’m obviously losing my mind anyway though so i guess i don’t need to worry too much.

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