DI 24505.025: Evaluation of Mental Impairments

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~~Effective Dates: 07/07/2017 - Present~~
Effective Dates: 01/08/2018 - Present
BASIC (10-01)
DI 24505.025 Evaluation of Mental Impairments
Citations:
Regulations No. 4, sections 404.1520a; and
Regulations No. 16, sections 416.920a
A. Policy - general
The steps outlined in DI 22001.000 apply to the evaluation of physical and mental impairments. In addition, when evaluating the severity of mental impairments for adults (persons age 18 and over) and in persons under age 18 when Part A of the Listing of Impairments is used, follow a special technique, described in DI 24505.025B through DI 24505.025D. Using the technique helps:
* Identify the need for additional evidence to determine impairment severity;
* Consider and evaluate functional consequences of the mental disorder(s) relevant to the ability to work; and
* Organize and present findings in a clear, concise, and consistent manner.
B. Policy - use of the technique
* First, evaluate the pertinent symptoms, signs, and laboratory findings to determine whether the claimant has a medically determinable mental impairment(s). See DI 22511.003 for further information about what is needed to show a medically determinable mental impairment(s). Consider and discuss alleged symptom-related limitations attributable to a medically determinable mental impairment in accordance with DI 24505.021 and DI 24515.062. Document the symptoms, signs, and laboratory findings that substantiate the presence of the impairment(s). See DI 24505.025E.
* Then, rate the degree of functional limitation resulting from the impairment(s) in accordance with DI 24505.025C and record the findings as set out in DI 24505.025E, including considerations of the claimant’s alleged symptom-related limitations in accordance with DI 24505.021.
C. Policy - rating the degree of functional limitation
* Assessment of functional limitations is a complex and highly individualized process that requires consideration of multiple issues and all relevant evidence to obtain a longitudinal picture of the claimant's overall degree of functional limitation. Consider all relevant and available clinical signs and laboratory findings, the effects of symptoms, and how functioning may be affected by factors including, but not limited to, chronic mental disorders, structured settings, medication, and other treatment.
* Rate the degree of functional limitation based on the extent to which the impairment(s) interferes with the claimant's ability to function independently, appropriately, effectively, and on a sustained basis. Thus, consider such factors as the quality and level of overall functional performance, any episodic limitations, the amount of supervision or assistance required, and the settings in which the claimant is able to function. See DI 34001.032 (12.00C through H of the Listing of Impairments) for more information about the factors to consider when rating the degree of functional limitation.
* Rate the degree of functional limitation in four broad functional areas: Activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation. See DI 34001.032 (12.00C of the Listing of Impairments).
* When rating the degree of limitation in the first three functional areas (activities of daily living; social functioning; and concentration, persistence, or pace), use the following five-point scale: None, mild, moderate, marked, and extreme. When rating the degree of limitation in the fourth functional area (episodes of decompensation), use the following four-point scale: None, one or two, three, four or more. The last point on each scale represents a degree of limitation that is incompatible with the ability to do any gainful activity.
D. Policy - use of the technique to evaluate mental impairments
After rating the degree of functional limitation resulting from the impairment(s), determine the severity of the mental impairment(s).
* If the degree of limitation in the first three functional areas is “none” or “mild” and “none” in the fourth area, we generally conclude that the impairment(s) is not severe, unless the evidence otherwise indicates that there is more than a minimal limitation in the ability to do basic work activities.
* If the mental impairment is severe, then determine if it meets or is equivalent in severity to a listed mental disorder. Do this by comparing the diagnostic medical findings about the impairment(s) and the rating of the degree of functional limitation to the criteria of the appropriate listed mental disorder. Record the presence or absence of the criteria and the rating of the degree of functional limitation on a standard document. See DI 24505.025 E.
If the claimant has a severe mental impairment(s) that neither meets nor is equivalent in severity to any listing, then assess residual functional capacity.
E. Policy - documenting application of the technique
Complete a standard document to record application of the technique. Except in cases in which a disability hearing officer makes the reconsideration determination (see DI 12026.000), the medical or psychological consultant has overall responsibility for assessing medical severity. The disability examiner, a member of the adjudicative team, may assist in preparing the standard document. However, the medical or psychological consultant must review and sign the document to attest that it is complete and that he or she is responsible for its content, including the findings of fact and any discussion of supporting evidence.
F. Procedure - use of the Psychiatric Review Technique Form (PRTF) - SSA-2506-BK
1. The Psychiatric Review Technique Form
The “standard document” used to document application of this Psychiatric Review Technique is the Psychiatric Review Technique Form (PRTF), SSA-2506-BK.
2. Before completing the PRTF
Using the PRTF appropriately requires a thorough knowledge of the preface to the mental disorders listings, 12.00A to 12.00I, and the listings themselves, 12.02 to 12.10, (see DI 34001.032), as well as knowledge of related program policies, such as the methods for equaling listings (see DI 24505.015).
3. Completing the PRTF at the initial and reconsideration levels
Either the disability examiner (DE) or the medical or psychological consultant (MC or PC) may complete the PRTF at the initial and reconsideration levels. However, the MC or PC has overall responsibility for assessing medical severity and for the content of the form.
4. Signing the PRTF
The MC or PC must sign the form to attest that it is complete and that he or she is responsible for its content, including the findings of fact and any discussion of supporting evidence. For determinations that are less than fully favorable, the MC or PC must be a psychiatrist or psychologist.
If the signed PRTF reflects that the MCs or PCs findings complete the medical portion of the determination, the MC or PC is not required to sign the Disability Determination and Transmittal form (SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3). See DI 26510.090C for procedures.
G. Description of the PRTF
The PRTF consists of a heading and four sections: Section I - Medical Summary; Section II - Documentation Of Factors That Evidence The Disorder; Section III - Rating Of Functional Limitations; Section IV - Consultant's Notes. Adjudicators use these sections to record information that is necessary to evaluate the mental impairment(s).
Adjudicators may record any other information or remarks in any section of the PRTF that assist in evaluating the mental impairment(s) or in explaining the disposition of the case. The information or explanation within the PRTF should support the medical summary in section I.
H. Procedure - how to complete the PRTF
1. Heading
Record the claimant's name and Social Security Number (SSN) in this section. When the claim is filed under an SSN that is different from the claimant's SSN, use the space labeled “NH” (number holder) to record the name and SSN under which the claim is filed.
2. Section I - medical summary
This section presents the PRTF findings based on a review of the medical evidence. FILL OUT THIS SECTION ONLY AFTER COMPLETING SECTIONS II THROUGH IV.
a. Section IA - assessment period
Record the time period the assessment covers. For example, the assessment may cover a time period 12 months after the alleged onset or the assessment may be from the date of a traumatic brain injury to the present. Consider all administrative and medical issues that may apply, such as date last insured or a closed period of disability.
b. Section IB - medical disposition(s).
* Disposition 1) No medically Determinable Impairment
* Check this block when the medical evidence does not establish the presence of a medically determinable mental impairment(s).
* Disposition 2) Impairment(s) Not Severe
* Check this block when the medical evidence establishes the presence of a medically determinable mental impairment(s), but the impairment(s) does not significantly limit the individual's ability to do basic work activities.
* Disposition 3) Impairment(s) Severe But Not Expected to Last 12 Months
* Check this block when the medical evidence establishes the presence of a medically determinable severe mental impairment(s) that is not expected (or did not) last for a period of 12 continuous months or result in death.
* Disposition 4) Meets Listing
* Check this block when the medical evidence establishes the presence of a medically determinable severe mental impairment(s) that satisfies the diagnostic description in the introductory paragraph and the criteria of the listing category(ies) 12.02 through 12.10. In the space provided, record the listing and subsections that are met; for example, 12.04A.1 and B.2,4.
* Disposition 5) Equals Listing
* Check this block when the symptoms, signs, and laboratory findings that establish the presence of the medically determinable mental impairment(s) are at least equal in significance to the criteria in the listing category(ies) 12.02 through 12.10. In the space provided, record the listing and subsections that are equaled.
* Disposition 6) RFC Assessment Necessary
* Check this block when the medically determinable mental impairment(s) does not meet or equal one of the listing categories 12.02 through 12.10, but is, nonetheless, severe; that is, the impairment(s) significantly limits the individual's ability to do basic work activities.
* Disposition 7) Coexisting Nonmental Impairment)s) that Requires Referral to Another Medical Specialty
* Check this block when there is a coexisting nonmental impairment(s) that must be referred to another medical specialty because the adjudicative team cannot make the assessment. For example, the coexisting impairment may be a musculoskeletal impairment that should be reviewed by an orthopedist. Make these referrals following internal office procedures.
* Disposition 8) Insufficient Evidence
* Check this block when the evidence in the case file is insufficient to make a disposition under 1 through 7. If additional evidence comes in before the final case disposition, prepare a new PRTF and discard the previously completed PRTF.
c. Section IC - category(ies) upon which the medical disposition(s) is based
In this section, check the appropriate listing category(ies) (12.02 through 12.10) when the documented symptoms, signs, and laboratory findings (including psychological test findings) establish the presence of the disorder. Checking a listing category is merely an indication that the findings are present in that category, and not an indication of the severity of the disorder.
Symptoms and signs generally cluster together to constitute a single recognizable mental disorder. However, if two or more mental disorders are definitely clinically present, check two or more listing categories.
d. Signature blocks
In the space provided at the bottom of page one of the PRTF, the MC or PC must sign, date, and record his or her specialty code after completing all appropriate parts of sections I through IV.
If the MC or PC chooses to sign only the PRTF and not the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3, check the block immediately above the signature blocks stating that the PRTF completes the medical portion of the determination. (See DI 26510.089 for the relationship between signature requirements on the PRTF and the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3.)
If the MC or PC chooses to sign only the PRTF and not the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3, check the block immediately above the signature blocks stating that the PRTF completes the medical portion of the determination.
3. Section II - documentation of factors that evidence the disorder
Section II has nine subsections A through I, which reflect the nine diagnostic categories of the mental disorders in listings 12.02 through 12.10. COMPLETE ONLY THOSE SUBSECTIONS THAT ADDRESS AN ALLEGED OR DOCUMENTED IMPAIRMENT.
The first check block in each subsection corresponds to a brief diagnostic description of the listed disorder(s). The paragraph “A” criteria of that listing, the symptoms, signs, and laboratory findings that establish the presence of the listed disorder(s) follow. Check the appropriate blocks to show both the disorder and the paragraph “A” criteria that are documented by the evidence. Do not consider the “A” criteria in isolation from the diagnostic description of the disorder. Checking paragraph “A” criteria does not necessarily mean that the listing is met, equaled, or that the impairment is severe. It simply means that the checked criteria are present.
If a diagnosis presented in the case record is not supported by the symptoms, signs, and laboratory findings, or the findings support a diagnosis other than the one presented in the case record, clarify the diagnosis with the medical source that provided the diagnosis. Provide an explanation in section IV (Consultant's Notes) when the impairment you record on the PRTF is different from the diagnosis presented by the medical source.
Use the check block and space positioned below the numbered diagnostic criteria in each subsection to identify any medically determinable mental impairment that is present, but does not precisely satisfy the paragraph “A” criteria of the listing. Also use this block when the evidence documents the presence of an unlisted disorder that should be assessed in the subsection. For example, if the evidence establishes the presence of dysthymia, evaluate it in subsection C (12.04 Affective Disorders). Record the pertinent symptoms, signs, and laboratory findings that establish the presence of the unlisted disorder.
If the file suggests the presence of a listed disorder, but the evidence is insufficient to establish the presence of the disorder, check the last block in the corresponding subsection. For example, if the claimant alleges an impairment such as depression or the treating source gives a diagnosis of depression but the evidence does not document the presence of the disorder, check the last block. If this occurs, explain the inadequacies and indicate what additional evidence is needed in section IV (Consultant's Notes).
In addition:
IF:
THEN:
You check any of the listing categories 12.02, 12.03, 12.04, 12.06, 12.07, 12.08, or 12.10…
Complete section III (Rating of Functional Limitations).
You check listing category 12.05, item 1 (12.05A) or item 2 (12.05B)…
The listing is satisfied. Do not complete section III.
You check listing category 12.05, item 3 (12.05C) and the additional impairment is a mental impairment…
Complete section III to show whether the additional mental impairment results in more than a minimal limitation in the ability to do basic work activities.
You check listing category 12.05, item 3 (12.05C) and the additional impairment is a physical impairment…
Identify the physical impairment in section IV (Consultant's Notes) and explain whether the physical impairment results in more than a minimal limitation in the ability to do basic work activities.
You check listing category 12.05, item 4 (12.05D)…
Complete section III to show whether 2 functional areas are limited at a marked level or 1 functional area is limited at an extreme level.
You check listing category 12.09, items 1, 2, 3, or 4 (12.09A - D)…
Complete section III. In addition, check, in the corresponding subsection (IIA, IIC, IIE, or IIG), the numbered items that document those symptoms, signs, and laboratory findings that are present as a result of regular use of addictive substances. Do not check the first block in the corresponding subsection (IIA, IIC, IIE, IIG) unless the evidence establishes the presence of the mental disorder separate from the substance addiction disorder.
You check listing category 12.09, items 5, 6, 7, 8, or 9 (12.09E - I)…
Do not complete section III. Evaluate under the appropriate physical listings. If referral to another medical specialty is needed, check item B7 in section I (Medical Summary).
4. Section III - rating of functional limitations
a. Section IIIA - “B” criteria of listings
Use this section to rate the degree of functional limitations imposed by the medically determinable impairment(s) identified in section II. In the space provided at the top of page 11, specify the listing(s) under which you are rating the functional limitations. Use items 1 through 4 on page 11 to rate the degree of limitation.
When rating listing 12.05C, if the additional impairment is a mental impairment, record 12.05C in the space provided and identify the additional mental disorder by name rather than by the listing number. Use items 1 through 4 on page 11 to rate the degree of limitation resulting from the additional mental impairment.
Rate the degree the impairment interferes with the ability to function independently, appropriately, effectively, and on a sustained basis in four broad areas of functioning. These four broad areas of functioning (items 1 through 4 on page 11) are the “B” criteria of the listings: Activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation. See DI 34001.032 (12.00C through H) for a discussion of the “B” criteria. See DI 24505.025C. and DI 24505.025D. for a discussion of the rating scale.
b. Section IIIB - “C” criteria of listings
Section IIIB contains additional functional criteria (paragraph “C” criteria) in listings 12.02, 12.03, 12.04, and 12.06. Use the paragraph “B” criteria first. Use the paragraph “C” criteria in these listings only if the paragraph “B” criteria are not satisfied. See DI 34001.032 (12.00E through G) for a discussion of the “C” criteria.
Check the first block in section IIIB1 when the “B” criteria are not satisfied and the evidence documents a history of a chronic organic mental (12.02), schizophrenic (12.03), or affective (12.04) disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to do any basic work activity. Checking item 1, 2, or 3 satisfies the criteria of these listings. Check Item 1 only if the repeated episodes of decompensation match the description provided in the explanation of the B4 criterion.
Section IIIB1 also contains two additional check blocks. Use the first of these additional blocks if the evidence does not establish the presence of the “C” criteria; that is,
* the evidence does not establish the presence of a chronic disorder;
or
* the evidence establishes the presence of a chronic disorder (the first block in IIIB1 is checked), but none of the severity criteria is satisfied. For example: The claimant alleges that due to a chronic schizophrenic impairment, he or she cannot function without the structure and constant support provided by his or her family. However, the evidence reveals that the claimant functions independently except for an occasional need for help to complete some complex activities. Even though the evidence establishes the presence of a chronic impairment, the occasional need for help does not satisfy the severity requirements of any of the “C” criteria.
Check the other additional block if the record contains insufficient evidence to document the presence of the “C” criteria. For example, if the claimant alleges a history of a chronic schizophrenic disorder, but there is insufficient evidence in the file to document the presence of this disorder; or there is evidence to document at least a 2-year history of the disorder, but insufficient evidence to document the presence of any of the three severity criteria. If you check the last block in section IIIB1, provide an explanation in section IV, (Consultant's Notes).
Check the first block in section IIIB2 when the “B” criteria are not satisfied and the evidence establishes the presence of agoraphobia (12.06) resulting in the complete inability to function independently outside the area of one's home. (If this is the case, and the 12.06 “A” criteria are satisfied, the impairment meets listing 12.06.)
Check the second block in IIIB2 when the evidence does not establish the complete inability to function independently outside the area of one's home.
Check the third block in IIIB2 when there is insufficient evidence to establish the complete inability to function outside the area of one's home. In this circumstance, provide an explanation in section IV, Consultant's Notes.
5. Section IV - consultant's notes
Complete this section to clarify or supplement the assessments in sections I, II, or III. For example, if the claimant is able to complete a variety of simple tasks, but you have rated B3 “marked” because the claimant must be constantly supervised, explain this rating in section IV. In addition, record any additional information or explanation necessary to support the medical summary in section I.
I. Procedure - adoption of the initial level PRTF
In reconsideration determinations, you may adopt the initial level PRTF without completing a new PRTF if the evidence does not warrant any change in the initial determination in any way. Enter the following statement in section IV (Consultant's Notes) of the initial level PRTF: “I have reviewed all the evidence in file, and the PRTF of [date] is affirmed as written.” This statement must be signed, dated, and annotated with the specialty code by the MC or PC (other than the MC or PC who signed the PRTF for the initial determination).
J. Procedure - disposition of Form SSA-2506-BK (PRTF)
Prong-file the final, signed PRTF on the right side of the folder (in the yellow section of the multi-part folder labeled Medical Records).

POMS Reference

DI 24505.025: Evaluation of Mental Impairments