DI 24510.006: Assessing Residual Functional Capacity (RFC) in Initial Claims (SSR 96-8p)

changes
←	*	→

~~Effective Dates: 08/08/2018 - Present~~
Effective Dates: 08/09/2018 - Present
TN 49 (09-96)
DI 24510.006 Assessing Residual Functional Capacity (RFC) in Initial Claims (SSR 96-8p)
Citations:
Sections 223(d) and 1614(a) of the Social Security Act
Social Security Act, as amended.
Regulations No. 4, subpart P, sections 404.1513, 404.1520, 404.1520a, 404.1545, 404.1546, 404.1560, 404.1561, 404.1569a, and appendix 2; and
Regulations No. 16, subpart I, sections 416.913, 416.920, 416.920a, 416.945, 416.946, 416.960, 416.961, and 416.969a.
A. Introduction
In disability determinations and decisions made at steps 4 and 5 of the sequential evaluation process in 20 CFR 404.1520 and 416.920, in which the individual's ability to do past relevant work and other work must be considered, the adjudicator must assess RFC. This Ruling clarifies the term “RFC” and discusses the elements considered in the assessment. It describes concepts for both physical and mental RFC assessments.
This Ruling applies to the assessment of RFC in claims for initial entitlement to disability benefits under titles II and XVI. Although most rules and procedures regarding RFC assessment in deciding whether an individual's disability continues are the same, there are some differences.
B. Policy - General
When an individual is not engaging in substantial gainful activity and a determination or decision cannot be made on the basis of medical factors alone (i.e., when the impairment is “severe” because it has more than a minimal effect on the ability to do basic work activities yet does not meet or equal in severity the requirements of any impairment in the Listing of Impairments), the sequential evaluation process generally must continue with an identification of the individual's functional limitations and restrictions and an assessment of his/her remaining capacities for work-related activities.
However, a finding of “disabled” will be made for an individual who:
* has a severe impairment(s),
* has no past relevant work,
* is age 55 or older, and
* has no more than a limited education.
See SSR 82-63, “Titles II/XVI: Medical-Vocational Profiles Showing an Inability to Make an Adjustment to Other Work.” In such a case, it is not necessary to assess the individual's RFC to determine if he/she meets this special profile and is, therefore, disabled. This assessment of RFC is used at step 4 of the sequential evaluation process to determine whether an individual is able to do past relevant work, and at step 5 to determine whether an individual is able to do other work, considering his/her age, education, and work experience.
1. Definition of RFC
RFC is what an individual can still do despite his/her limitations. RFC is an administrative assessment of the extent to which an individual's medically determinable impairment(s), including any related symptoms, such as pain, may cause physical or mental limitations or restrictions that may affect his/her capacity to do work-related physical and mental activities.
REFERENCE: Evaluation of Symptoms in Disability Claims; Assessing the Credibility of Individual's Statements (SSR 96-7p), DI 24515.066.
2. Description of RFC
Ordinarily, RFC is the individual's maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis, and the RFC assessment must include a discussion of the individual's abilities on that basis. A “regular and continuing basis” means a 8 hours a day, for 5 days a week, or an equivalent work schedule. (The ability to work 8 hours a day, for 5 days a week is not always required when evaluating an individual's ability to do past relevant work at step 4 of the sequential evaluation process. Part-time work that was substantial gainful activity, performed within the past 15 years, and lasted long enough for the person to learn to do it constitutes past relevant work, and an individual who retains the RFC to perform such work must be found not disabled.) RFC does not represent the least an individual can do despite his/her limitations or restrictions, but the most. (See SSR 83-10, “Titles II and XVI: Determining Capability to Do Other Work—The Medical Vocational Rules of Appendix 2”.) SSR 83-10 states that “(T)he RFC determines a work capability that is exertionally sufficient to allow performance of at least substantially all of the activities of work at a particular level (e.g., sedentary, light, or medium), but is also insufficient to allow substantial performance of work at greater exertional levels.”) RFC is assessed by adjudicators at each level of the administrative review process based on all of the relevant evidence in the case record, including information about the individual's symptoms and any “medical source statements”—i.e., opinions about what the individual can still do despite his/her impairment(s)—submitted by an individual's treating source or other acceptable medical sources. For a detailed discussion of the difference between the RFC assessment, which is an administrative finding of fact, and the opinion evidence called the “medical source statement” or “MSS,”
NOTE: SSR 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements” has been replaced with SSR 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims.” Effective 3/28/16, we no longer use the term “credibility” when evaluating symptoms.
C. Policy - RFC Assessment
The RFC Assessment Must be Based Solely on the Individual's Impairment(s)
The Act requires that an individual's inability to work must result from the individual's physical or mental impairment(s). Therefore, in assessing RFC, the adjudicator must consider only limitations and restrictions attributable to medically determinable impairments. It is incorrect to find that an individual has limitations or restrictions beyond those caused by his or her medical impairment(s) including any related symptoms, such as pain, due to factors such as age or height, or whether the individual had ever engaged in certain activities in his or her past relevant work (e.g., lifting heavy weights.) Age and body habitus (i.e., natural body build, physique, constitution, size, and weight, insofar as they are unrelated to the individual's medically determinable impairment(s) and related symptoms) are not factors in assessing RFC in initial claims. (The definition of disability in the Act requires that an individual's inability to work must be due to a medically determinable physical or mental impairment(s). The assessment of RFC must therefore be concerned with the impact of a disease process or injury on the individual. In determining a person's maximum RFC for sustained activity, factors of age or body habitus must not be allowed to influence the assessment.)
Likewise, when there is no allegation of a physical or mental limitation or restriction of a specific functional capacity, and no information in the case record that there is such a limitation or restriction, the adjudicator must consider the individual to have no limitation or restriction with respect to that functional capacity.
1. RFC and Sequential Evaluation
RFC is an issue only at steps 4 and 5 of the sequential evaluation process. The following are issues regarding the RFC assessment and its use at each of these steps.
2. RFC and Exertional Levels of Work
The RFC assessment is a function-by-function assessment based upon all of the relevant evidence of an individual's ability to do work-related activities. At step 4 of the sequential evaluation process, the RFC must not be expressed initially in terms of the exertional categories of “sedentary,” “light,” “medium,” “heavy,” and “very heavy” work because the first consideration at this step is whether the individual can do past relevant work as he/she actually performed it.
RFC may be expressed in terms of an exertional category, such as light, if it becomes necessary to assess whether an individual is able to do his or her past relevant work as it is generally performed in the national economy. However, without the initial function-by-function assessment of the individual's physical and mental capacities, it may not be possible to determine whether the individual is able to do past relevant work as it is generally performed in the national economy because particular occupations may not require all of the exertional and nonexertional demands necessary to do the full range of work at a given exertional level.
At step 5 of the sequential evaluation process, RFC must be expressed in terms of, or related to, the exertional categories when the adjudicator determines whether there is other work the individual can do. However, in order for an individual to do a full range of work at a given exertional level, such as sedentary, the individual must be able to perform substantially all of the exertional and nonexertional functions required in work at that level. Therefore, it is necessary to assess the individual s capacity to perform each of these functions in order to decide which exertional level is appropriate and whether the individual is capable of doing the full range of work contemplated by the exertional level.
Initial failure to consider an individual's ability to perform the specific work-related functions could be critical to the outcome of a case. For example:
* At step 4 of the sequential evaluation process, it is especially important to determine whether an individual who is at least “closely approaching advanced age” is able to do past relevant work because failure to address this issue at step 4 can result in an erroneous finding that the individual is disabled at step 5. It is very important to consider first whether the individual can still do past relevant work as he/she actually performed it because individual jobs within an occupational category as performed for particular employers may not entail all of the requirements of the exertional level indicated for that category in the Dictionary of Occupational Titles and its related volumes.
* The opposite result may also occur at step 4 of the sequential evaluation process. When it is found that an individual cannot do past relevant work as he or she actually performed it, the adjudicator must consider whether the individual can do the work as it is generally performed in the national economy. Again, however, a failure to first make a function-by-function assessment of the individual's limitations or restrictions could result in the adjudicator overlooking some of an individual's limitations or restrictions. This could lead to an incorrect use of an exertional category to find that the individual is able to do past relevant work as it is generally performed and an erroneous finding that the individual is not disabled.
* At step 5 of the sequential evaluation process, the same failures could result in an improper application of the rules in appendix 2 to subpart P of the Regulations No. 4 (the “Medical-Vocational Guidelines” ) and could make the difference between a finding of “disabled” and “not disabled.” Without a careful consideration of an individual's functional capacities to support an RFC assessment based on an exertional category, the adjudicator may either overlook limitations or restrictions that would narrow the ranges and types of work an individual may be able to do, or find that the individual has limitations or restrictions that he or she does not actually have.
3. RFC Represents the Most Despite limitations or Restrictions
RFC represents the most that an individual can do despite his/her limitations or restrictions.
At step 5 of the sequential evaluation process, RFC must not be expressed in terms of the lowest exertional level (e.g., “sedentary” or “light” when the individual can perform “medium” work) at which the medical-vocational rules would still direct a finding of “not disabled.” This would concede lesser functional abilities than the individual actually possesses and would not reflect the most he/she can do based on the evidence in the case record, as directed by the regulations. (In the Fourth Circuit, adjudicators are required to adopt a finding, absent new and material evidence, regarding the individual's RFC made in a final decision by an administrative law judge or the Appeals Council on a prior disability claim arising under the same title of the Act. In this jurisdiction, an unfavorable determination or decision using the lowest exertional level at which the rules would direct a finding of not disabled could result in an unwarranted favorable determination or decision on an individual's subsequent application; for example, if the individual's age changes to a higher age category following the final decision on the earlier application. See Acquiescence Ruling (AR) 94-2(4), “Lively v. Secretary of Health and Human Services , 820 F.2d 1391 (4th Cir. 1987)—Effect of Prior Disability Findings on Adjudication of a Subsequent Disability Claim Arising Under the Same Title of the Social Security Act—Titles II and XVI of the Social Security Act.” AR 94-2(4) applies to disability findings in cases involving claimants who reside in the Fourth Circuit at the time of the determination or decision on the subsequent claim.)
NOTE: AR 94-2(4), Lively v. Secretary of Health and Human Services, was rescinded on January 12, 2000, and replaced by AR 00-1(4) Albright v. Commissioner of the Social Security Administration (DI 52715.000). See also DI 52705.000 and DI 52706.000.
4. Psychiatric Review
The psychiatric review Technique
The psychiatric review technique described in 20 CFR 404.1520a and 416.920a and summarized on the Psychiatric Review Technique Form (PRTF) requires adjudicators to assess an individual's limitations and restrictions from a mental impairment(s) in categories identified in the “paragraph B” and “paragraph C” criteria of the adult mental disorders listings. The adjudicator must remember that the limitations identified in the “paragraph B” and “paragraph C” criteria are not an RFC assessment but are used to rate the severity of mental impairment(s) at steps 2 and 3 of the sequential evaluation process. The mental RFC assessment used at steps 4 and 5 of the sequential evaluation process requires a more detailed assessment by itemizing various functions contained in the broad categories found in paragraphs B and C of the adult mental disorders listings in 12.00 of the Listing of Impairments, and summarized on the PRTF.
5. Evidence Considered
The RFC assessment must be based on all of the relevant evidence in the case record, such as:
* Medical history,
* Medical signs and laboratory findings,
* The effects of treatment, including limitations or restrictions imposed by the mechanics of treatment (e.g., frequency of treatment, duration, disruption to routine, side effects of medication),
* Reports of daily activities,
* Lay evidence,
* Recorded observations,
* Medical source statements,
* Effects of symptoms, including pain, that are reasonably attributed to a medically determinable impairment,
* Evidence from attempts to work,
* Need for a structured living environment, and
* Work evaluations, if available.
The adjudicator must consider all allegations of physical and mental limitations or restrictions and make every reasonable effort to ensure that the file contains sufficient evidence to assess RFC. Careful consideration must be given to any available information about symptoms because subjective descriptions may indicate more severe limitations or restrictions than can be shown by objective medical evidence alone.
In assessing RFC, the adjudicator must consider limitations and restrictions imposed by all of an individual's impairments, even those that are not “severe.” While a “not severe” impairment(s) standing alone may not significantly limit an individual's ability to do basic work activities, it may — when considered with limitations or restrictions due to other impairments — be critical to the outcome of a claim. For example, in combination with limitations imposed by an individual's other impairments, the limitations due to such a “not severe” impairment may prevent an individual from performing past relevant work or may narrow the range of other work that the individual may still be able to do.
6. Exertional and Nonexertional Functions
The RFC assessment must address both the remaining exertional and nonexertional capacities of the individual.
a. Exertional Capacity
Exertional capacity addresses an individual's limitations and restrictions of physical strength and defines the individual's remaining abilities to perform each of seven strength demands: Sitting, standing, walking, lifting, carrying, pushing, and pulling. Each function must be considered separately (e.g., “the individual can walk for 5 out of 8 hours and stand for 6 out of 8 hours”), even if the final RFC assessment will combine activities (e.g., “walk/stand, lift/carry, push/pull”). Although the regulations describing the exertional levels of work and the Dictionary of Occupational Titles and its related volumes pair some functions, it is not invariably the case that treating the activities together will result in the same decisional outcome as treating them separately.
It is especially important that adjudicators consider the capacities separately when deciding whether an individual can do past relevant work. However, separate consideration may also influence decisionmaking at step 5 of the sequential evaluation process, for reasons already given in the section on “RFC and Sequential Evaluation.”
b. Nonexertional Capacity
Nonexertional capacity considers all work-related limitations and restrictions that do not depend on an individual's physical strength; i.e., all physical limitations and restrictions that are not reflected in the seven strength demands, and mental limitations and restrictions. It assesses an individual's abilities to perform physical activities such as postural (e.g., stooping, climbing), manipulative (e.g., reaching, handling), visual (seeing), communicative (hearing, speaking), and mental (e.g., understanding and remembering instructions and responding appropriately to supervision). In addition to these activities, it also considers the ability to tolerate various environmental factors (e.g., tolerance of temperature extremes).
As with exertional capacity, nonexertional capacity must be expressed in terms of work-related functions. For example, in assessing RFC for an individual with a visual impairment, the adjudicator must consider the individual's residual capacity to perform such work-related functions as working with large or small objects, following instructions, or avoiding ordinary hazards in the workplace. In assessing RFC with impairments affecting hearing or speech, the adjudicator must explain how the individual's limitations would affect his/her ability to communicate in the workplace. Work-related mental activities generally required by competitive, remunerative work include the abilities to: understand, carry out, and remember instructions; use judgment in making work-related decisions; respond appropriately to supervision, co-workers and work situations; and deal with changes in a routine work setting.
c. Consider the Nature of the Activity Affected
It is the nature of an individual's limitations or restrictions that determines whether the individual will have only exertional limitations or restrictions, only nonexertional limitations or restrictions, or a combination of exertional and nonexertional limitations or restrictions. For example, symptoms, including pain, are not intrinsically exertional or nonexertional. Symptoms often affect the capacity to perform one of the seven strength demands and may or may not have effects on the demands of occupations other than the strength demands. If the only limitations or restrictions caused by symptoms, such as pain, are in one or more of the seven strength demands (e.g., lifting) the limitation or restriction will be exertional. On the other hand, if an individual's symptoms cause a limitation or restriction that affects the individual's ability to meet the demands of occupations other than their strength demands (e.g., manipulation or concentration), the limitation or restriction is classified as nonexertional. Symptoms may also cause both exertional and nonexertional limitations.
Likewise, even though mental impairments usually affect nonexertional functions, they may also limit exertional capacity by affecting one or more of the seven strength demands. For example, a mental impairment may cause fatigue or hysterical paralysis.
7. Narrative Discussion Requirements
The RFC assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations). In assessing RFC, the adjudicator must discuss the individual's ability to perform sustained work activities in an ordinary work setting on a regular and continuing basis (i.e., 8 hours a day, for 5 days a week, or an equivalent work schedule), and describe the maximum amount of each work-related activity the individual can perform based on the evidence available in the case record. The adjudicator must also explain how any material inconsistencies or ambiguities in the evidence in the case record were considered and resolved.
a. Symptoms
In all cases in which symptoms, such as pain, are alleged, the RFC assessment must:
* Contain a thorough discussion and analysis of the objective medical and other evidence, including the individual's complaints of pain and other symptoms and the adjudicator's personal observations, if appropriate;
* Include a resolution of any inconsistencies in the evidence as a whole; and
* Set forth a logical explanation of the effects of the symptoms, including pain, on the individual's ability to work.
The RFC assessment must include a discussion of why reported symptom-related functional limitations and restrictions can or cannot reasonably be accepted as consistent with the medical and other evidence. In instances in which the adjudicator has observed the individual, he/she is not free to accept or reject that individual's complaints solely on the basis of such personal observations. (For further information about RFC assessment and the evaluation of symptoms, see DI 24515.066, Evaluation of Symptoms in Disability Claims; Assessing the Credibility of an Individual's Statements (SSR 96-7p)
b. Medical Opinions
The RFC assessment must always consider and address medical source opinions. If the RFC assessment conflicts with an opinion from a medical source, the adjudicator must explain why the opinion was not adopted.
Medical opinions from treating sources about the nature and severity of an individual's impairment(s) are entitled to special significance and may be entitled to controlling weight. If a treating source's medical opinion on an issue of the nature and severity of an individual's impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, the adjudicator must give it controlling weight. (See DI 24515.004, Giving Controlling Weight to Treating Source Medical Opinions (SSR 96-2p) and DI 24515.009 Medical Source Opinions on Issues Reserved to the Commissioner (SSR 96-5p).) (A medical source opinion that an individual is “disabled” or “unable to work,” has an impairment(s) that meets or is equivalent in severity to the requirements of a listing, has a particular RFC, or concerns the application of vocational factors, is an opinion on an issue reserved to the Commissioner. Every such opinion must still be considered in adjudicating a disability claim; however, the adjudicator will not give any special significance to the opinion because of its source. See DI 24515.009. For further information about the evaluation of medical source opinions, see Consideration of Administrative Findings of Fact by State Agency Medical and Psychological Consultants and Other Program Physicians and Psychologists at the Administrative Law Judge and Appeals Council Levels of Administrative Review; Medical Equivalence (SSR 96-6p).)
NOTE: Some of the policies in subsection C. are obsolete. For current policy, see DI 24503.000 Evaluating Evidence. SSR 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements” has been replaced with SSR 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims.” Effective 3/28/16, we no longer use the term “credibility” when evaluating symptoms.
D. References
* SSR 82-52, “Titles II and XVI: Duration of the Impairment”;
* SSR 82-61, “Titles II and XVI: Past Relevant Work — The Particular Job Or the Occupation As Generally Performed”;
* SSR 82-62, “Titles II and XVI: A Disability Claimant's Capacity To Do Past Relevant Work, In General”;
* SSR 83-20, “Titles II and XVI: Onset of Disability”;
* SSR 85-16, “Titles II and XVI: Residual Functional Capacity for Mental Impairments”;
* SSR 86-8, “Titles II and XVI: The Sequential Evaluation Process”;
* DI 22515.035 Use of Work Evaluation, DI 24510.000 Residual Functional Capacity (RFC);
* Medical Equivalence, DI 22001.001D.3, DI 24501.021A.2;
* DI 24503.000 Evaluating Evidence;
* DI 25015.020, Determining Capability to Do Other Work — Implications of a Residual Functional Capacity for Less Than a Full Range of Sedentary Work (SSR 96-9p);
* Overview of Onset Policy, DI 25501.200 – DI 25501.470;
* Relating Medical Improvement to the Ability to Work, DI 28015.000.
NOTE: SSR 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims” has replaced SSR 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements.” Effective 3/28/2016, we no longer use the term “credibility” when evaluating symptoms. See also, POMS DI 24501.021 Evaluating Symptoms.

POMS Reference

DI 24510.006: Assessing Residual Functional Capacity (RFC) in Initial Claims (SSR 96-8p)