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). 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.