TN 2 (06-10)

Citations:

20 CFR 404.1508, 404.1521, 404.1528, 416.908, 416.921, 416.928, SSR 96-4p

A. Introduction

These instructions explain how to determine if further evidence development of a potential mental or physical impairment is necessary and how to expedite processing of such cases. This subsection defines terms specific to these instructions.

B. Alleged impairment

An alleged impairment is one that the claimant says he or she has or is the description, in the claimant’s own words, of the disabling condition.

References

• DI 22505.000, Development of Medical Evidence of Record (MER) Table of Contents

• DI 24505.025, Evaluation of Mental Impairments.

• DI 24510.050, Completion of the Physical RFC Assessment Form

• DI 24510.060 through DI 24510.065, Mental Residual Functional Capacity Assessment through Section III of SSA-4734-F4-SUP Functional Capacity Assessment – Functional Capacity Assessment

• DI 25200.000, Title XVI Child Claims Based on Disability – Table of Contents

C. Documented impairment

A properly documented impairment results from sufficient case development, medical evaluation, and documentation procedures and for which the evidence shows:

• the probable duration of the impairment,

• the nature and limiting effects of the individual's physical and mental impairments, and

• the claimant's residual functional capacity to do work-related physical and mental activities in cases requiring consideration of vocational factors.

D. Potential impairment

Claimants may not always allege an impairment on which disability can be found. You may discover a potential mental or physical impairment in medical evidence, lay evidence, on forms, or in conversation with the claimant or other source. For example, a potential impairment may be detected from a mere reference to a symptom or a limitation, but there is insufficient documentation in file to determine relevance to the disability determination or if further evidence development is necessary.

Determine if further evidence development of a potential impairment is necessary.

E. When a fully favorable allowance precludes the need for further evidence development of a potential mental or physical impairment

Discontinue development at the point when you can make a fully favorable allowance determination.

1. Fully favorable allowance based only on a physical impairment when a mental impairment is also alleged

Discontinue development when a fully favorable allowance is documented based on a physical impairment and a mental impairment is also alleged.

EXAMPLE: If the claimant alleges disability due to a back impairment and depression, and the evidence in file permits a fully favorable determination based on the back impairment, discontinue development of the mental impairment.

Complete an SSA-4734-BK, Physical Residual Functional Capacity Assessment, SSA-416, Case Analysis, or other appropriate document for the physical impairment.

2. Fully favorable allowance based only on a mental impairment when a physical impairment is also alleged

Discontinue development when a fully favorable allowance is documented based on a mental impairment and a physical impairment is also alleged.

EXAMPLE: If the claimant alleges disability due to a back impairment and depression, and the evidence in file permits a fully favorable determination based on the depression, discontinue development of the back impairment.

Complete an SSA-2506-BK, Psychiatric Review Technique, with appropriate signature, SSA-4734-F-SUP, Mental Residual Functional Capacity Assessment, if appropriate, SSA-416 Case Analysis, or other appropriate document for the mental impairment.

3. Fully favorable allowance based on a combination of physical and mental Impairments

Discontinue development when a fully favorable allowance is documented based on a combination of physical and mental impairments.

EXAMPLE: If the claimant alleges disability due to a back impairment and depression, and the evidence in file permits a fully favorable determination based on a combination of the two impairments, discontinue development.

Complete an SSA-4734-BK Physical Residual Functional Capacity Assessment, SSA-2506-BK Psychiatric Review Technique with appropriate signature, SSA-4734-F4-SUP Functional Capacity Assessment, SSA-416 Case Analysis, or other appropriate document.

F. When a potential mental or physical impairment requires further development

A potential mental or physical impairment requires further development when:

• treatment (such as a procedure, a therapy, or a medication) for a condition was recommended or received.

• evidence or contact with a medical source suggests that the potential impairment is a medically determinable impairment (MDI). See DI 24501.020 Symptoms, Signs, and Laboratory Findings; or

• evidence or contact with a medical source or the claimant (or a knowledgeable third party) supports limitations in basic work activities (or functional limitations for children) resulting from the potential mental or physical impairment.

For an explanation of basic work activities, see DI 24505.001C, Individual Must Have a Medically Determinable Severe Impairment.

For an explanation of functional limitations for children, see DI 25210.010, How Your Functioning Compares To The Functioning Of Children Your Age Who Do Not Have Impairments (Section 416.924a(b)(3)) and DI 25225.005, How We Will Consider Your Functioning (Section 416.926a(b)).

DO NOT DEVELOP evidence for a potential mental or physical impairment when:

• there is no recommendation or receipt of treatment for a condition;

• there is no medical evidence of an MDI; and

• there are no limitations in basic work activities (or functional limitations for children).

G. How to expedite further development of a potential mental or physical impairment when MER suggests a potential impairment

As early in case development as possible, consider expedited steps to contact the medical source, such as telephone, FAX, mail, or claimant assistance. In addition, you may request a Medical Consultant (MC) or Psychological Consultant (PC) to contact the medical source.

Ask the medical source focused questions that resolve whether the potential impairment has resulted in treatment, is secondary to an MDI, or has resulted in limitations in basic work activities (or functional limitations for children).

If the medical source cannot or will not provide the information, contact the claimant (or a responsible third party). See DI 24505.030H in this section.

1. Further develop the potential impairment when the medical source responds that:

• treatment for the condition was recommended or received;

• the potential additional impairment is an MDI; or

• there are limitations in basic work activities (or functional limitations for children).

NOTE: Consider whether the evidence, including any diagnostic tests or procedures already performed, is available from the claimant’s medical sources before deciding to purchase a Consultative Examination (CE).

Forms to complete

• Complete an SSA-4734-BK, Physical Residual Functional Capacity Assessment, SSA-416 Case Analysis, or other appropriate document.

• Complete an SSA-2506-BK Psychiatric Review Technique with appropriate signature, SSA-4734-F4-SUP Functional Capacity Assessment, SSA-416 Case Analysis, or other appropriate document if there is a documented mental impairment.

• Complete an SSA-538-F6 Childhood Disability Evaluation, Childhood Disability Evaluation Form with appropriate signatures for all title XVI childhood disability cases.

2. Do not further develop evidence for the potential impairment when the medical source responds that:

• treatment has not been recommended or received;

• the potential impairment is not an MDI; and

• there are no limitations in basic work activities (or functional limitations for children) reported by the medical source.

MC review and completion of an SSA-4734-BK Physical Residual Functional Capacity Assessment are NOT necessary for the potential physical impairment.

PC review and completion of an SSA-2506-BK Psychiatric Review Technique are NOT necessary for the potential mental impairment.

Explain why further development of the potential impairment was not done on the SSA-416 Case Analysis, SSA-5002 Report of Contact (RC), or in a similar entry in the file. In the explanation, cite the three factors (treatment not recommended or received, no MDI, and no limitations in basic work activities or functional limitations for children), for when no further development is required.

H. How to expedite further development of a potential mental or physical impairment when the claimant, third party, or other non-medical source suggests a potential impairment

Early in case development, contact the claimant (or a responsible third party). Ask him or her focused questions that resolve if the potential impairment has resulted in treatment, or has resulted in limitations in basic work activities (or functional limitations for children).

1. Further develop evidence for the potential impairment when the claimant, third party, or other non-medical source responds that:

• treatment for the condition has been recommended or received; or,

• there are limitations in basic work activities (or functional limitations for children).

NOTE: Consider whether the evidence, including any diagnostic tests or procedures already performed, is available from the claimant’s medical sources before deciding whether to purchase a CE.

Forms to complete

• Complete an SSA-4734-BK Physical Residual Functional Capacity Assessment, SSA-416 Case Analysis, or other appropriate document if there is a documented physical impairment.

• Complete an SSA-2506-BK Psychiatric Review Technique with appropriate signature if there is a documented mental impairment.

• Complete an SSA-538-F6 Childhood Disability Evaluation with appropriate signatures if there is a documented childhood impairment.

2. Do not further develop evidence for the potential impairment when the claimant, third party, or other non-medical source responds that:

• treatment has not been recommended or received and

• there are no limitations in basic work activities (or functional limitations for children)

  MC review and completion of an SSA-4734-BK Physical Residual Functional Capacity Assessment are NOT necessary for the potential physical impairment.

  PC review and completion of an SSA-2506-BK Psychiatric Review Technique are NOT necessary for the potential mental impairment.

  Explain why further development of the potential impairment was not done on an SSA-5002 Report of Contact or in a similar entry in the file. In the explanation, cite that treatment was not recommended or received, and there are no limitations in basic work activities (or functional limitations for children) from the potential impairment.

I. When there is no mental MDI but a physical impairment causes mental effects

When evidence shows that a potential mental condition is not a mental MDI, but instead results from a physical impairment, or from medication related to a physical impairment(s), document the effects on an SSA-4734-BK Physical Residual Functional Capacity Assessment, SSA-538-F6 Childhood Disability Evaluation, SSA-416 Case Analysis, SSA-5002 Report of Contact, or other appropriate document.

EXAMPLE: Evidence supports symptoms of anxiety about lifting after successful coronary bypass surgery. The medical source indicates that the claimant is capable of the lifting required by his or her past work and there is no indication of a mental MDI that is causing the anxiety.

The MC assessing the documented physical impairment(s) should address this anxiety (which is due to the physical impairment) on the SSA-4734-BK Physical Residual Functional Capacity Assessment, SSA-416 Case Analysis, or other appropriate medical review form. In the explanation, cite the three factors (treatment not recommended or received; no MDI; and no limitations in basic work activities, or functional limitations for children) for when no further development is required.

J. When there is no physical MDI, but a mental impairment causes physical effects

When evidence shows that a potential physical condition is not a physical MDI, but instead results from a mental impairment(s) or from psychiatric medication, document the effects on an SSA-2506-BK Psychiatric Review Technique, SSA 4734-F4-SUP, SSA-538-F6 Childhood Disability Evaluation, SSA-416 Case Analysis, or other appropriate mental impairment assessment form.

EXAMPLE: Evidence supports symptoms of trembling as a side effect of psychiatric medication or as a physical symptom of a mental impairment. The medical source indicates that the claimant is capable of the mental demands of work activity and there is no indication of a physical MDI that is causing the trembling.

The PC assessing the documented mental impairment(s) should address this trembling (which is due to the mental impairment) on the mental SSA-2506-BK Psychiatric Review Technique, SSA-4734-F4-SUP Functional Capacity Assessment, SSA-538-F6 Childhood Disability Evaluation, SSA-416 Case Analysis, SSA-5002 Report of Contact, or other appropriate medical review document. In the explanation, cite the three factors (treatment not recommended or received; no MDI; and no limitations in basic work activities, or functional limitations for children) for when no further development is required.