Social Security Disability Determinations and Consultative Exams

The consultative examination is ordered by Disability Determination Services, a state agency funded by the federal government. The DDS develops medical evidence at the initial level to determine eligibility for Social Security disability benefits.

You've submitted your disability application to the Social Security Administration (SSA). Then you get a notification from your local state Disability Determination Services (DDS). In this notification, DDS informs you that you must undergo a "consultative examination" (CE). This article discusses what a consultative examination is, when you may be asked to attend one, and other aspects of the process.

What Is the Consultative Examination Process?

Disability Determination Services may arrange and pay for a consultative examination if it needs additional information to make a decision.

During a consultative examination, a qualified medical source conducts a mental or physical examination or test. The medical source then submits the CE report to Disability Determination Services for the decision-makers to make a disability determination. An administrative law judge may also order a consultative examination before making a decision at the hearing level.

The decision-makers prefer that your treating source conducts the examination. But that treating doctor must be qualified to perform consultative examinations, trained and equipped for testing, and willing to perform the examination. Even if only one additional test is needed, the treating source is still generally the preferred source for this service.

The Social Security Administration's rules for using a medical source instead of your treating source include:

  • Your treating source is not willing or qualified to perform the consultative examination.
  • You have no other medical sources.
  • You object to using your treating source.
  • There is reason to question the treating source's quality or evidence.

When Is a Consultative Exam Necessary?

consultative exam may be necessary when:

  • There isn't enough medical information in your existing medical record for a disability determination.
  • The decision-makers cannot get evidence that may have been available from your own doctors for reasons beyond your control.
  • The decision maker requires highly technical or specialized medical evidence to determine disability.
  • There is an indication of a change in your condition that will likely affect your ability to work or, if the claimant is a child, will affect the child's functioning.

Requirements for the Consulting Doctor

The law requires that consulting sources follow specific requirements. The following is a list of the requirements a consultative examination must follow for a valid report:

Time Minimums

Consulting sources must spend a certain amount of time evaluating your medical condition. The time required depends on the nature of the consultative examination. For example, the following types of exams have the following time requirements:

  • General medical examination — at least 30 minutes
  • Musculoskeletal or neurological examination — at least 20 minutes
  • Psychiatric examination — at least 40 minutes
  • Psychological examination — at least 60 minutes (though more may be required depending on the types of psychological tests needed)
  • All other examinations — at least 30 minutes

Report Content

The consulting source's report must meet accepted medical standards and practices for a complete and competent examination. The information in the report will vary depending on the type of medical exam or testing. But it must contain enough information to allow the DDS to determine the nature, severity, and duration of the claimed impairment.

The report must also contain enough information for Disability Determination Services to determine your ability to perform basic work functions (for adults) or functioning (for children). Consulting sources must include symptoms, objective medical facts, and the consulting source's observations and opinions in the report. To constitute a complete consultative examination, the consulting doctor must record certain information, including the following:

  • The case identifier (SSN typically)
  • Your physical description and major complaint
  • Your physical or mental examination
  • A description of the relevant and detailed positive and negative findings based on your history, exam, and lab test results
  • A diagnosis and prognosis for the impairment
  • A statement about what work-related activities you can do despite the impairment

Importantly, the consulting doctor should not include an opinion about whether you are "disabled" under the meaning of the law. This is a finding left for disability decision-makers.

Review and Signature

The medical source must personally review and sign the report. A signature with the annotation "dictated but not read" or “not proofed" is not allowed.

Before and After the Consultative Exam

You should prepare to tell the disability examiner about your current symptoms and your past medical history. This may include things like medications, hospitalizations, and testing. You may also want to tell the examiner the primary reasons you can't work.

After the CE, you may want to write detailed information about the examination. For example, you may want to note the time the doctor spent with you and what tests, like a mental status examination, the doctor performed. You may also want to write down what the doctor asked you, what the doctor asked you to do, and whether you had an opportunity to explain your symptoms to the medical source.

Get Professional Help With Your Social Security Disability Claim

It is not always easy for disability claimants to understand the rules for entitlements under Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). If you are asked to attend a consultative examination and don't know what to do, or you don't believe you were treated fairly during a consultative examination, you may want to contact a Social Security disability attorney skilled in disability law. A Social Security disability lawyer can help explain your disability case and fight for the benefits to which you may be entitled. Get a head start and contact a skilled SSDI/SSI attorney near you today.

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  • An attorney primarily handles claims that are denied
  • It can be helpful to have an attorney during Social Security benefit disputes or appeals

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