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Home Page > Disability > Documenting Disability for Physicians

Physician’s Guide to Documenting Disability in Adult Social Security Claims

 

Your patients who apply for Social Security Disability (SSD) and Supplemental Security Income (SSI) need medical information from you to prove their claims. Timely medical information is critical in these situations. Without it, vulnerable patients can lose access to the most basic necessities of life, such as reliable sources of adequate food, shelter, and medical care. Patients who are legitimately unable to hold a job, but who cannot get timely medical documentation, can face financial ruin and loss of the safety-net benefits that they need to subsist.

Given the high stakes for your indigent patients, you can do a great service by providing the needed information. This presentation will focus on how to do so in an efficient, effective, and ethical manner.

Social Security Disability and Supplemental Security Income

I. Introduction: What are the Social Security Programs for People with Disabilities?

The Social Security Administration has two basic disability programs that provide cash monthly benefits and medical insurance. The first, called Supplemental Security Income (SSI), is available to adults and children with low income and resources. SSI beneficiaries may receive a maximum cash monthly benefit and Medicaid health insurance in New Jersey. The second, called Social Security Disability Insurance (SSD), is available to people who have worked long enough to qualify and sometimes their dependents. SSD beneficiaries receive cash monthly benefits in an amount based on their past earnings, and after a 24-month waiting period they receive Medicare health insurance. Both programs require proof of disability. Social Security considers medical, vocational, and educational information in deciding claims.

II. What is Social Security’s Standard for Disability?

The SSI and SSD program disability standard for adults requires that claimants be unable to engage in “substantial gainful work activity” because of a mental and/or physical disability that has lasted, or will last, for at least 12 months. Some work may be permissible as long as it is not substantial.
Social Security has a five-step method of determining disability:

  • Step One: Is the claimant working at “substantial” levels?
    If yes, deny the claim. If no, go to step two.
  • Step Two: Does the claimant have a “severe” impairment (a relatively easy standard)?
    If yes, go to step three. If no, deny the claim.
  • Step Three: Does the claimant meet or substantially equal the requirements of one of Social Security’s “Listed Impairments?” (Explained later)
    If yes, the claim is approved. If no, go to step four.
  • Step Four: Is the claimant able to do past relevant work?
    If yes, the claim is denied. If no, go to step five.
  • Step Five: Is the claimant able to do any other jobs existing in significant numbers in the national or local economy?
    If yes, the claim is denied. If no, the claim is approved.

When assessing a case at steps four and five, Social Security makes a determination of the claimant’s maximum physical and mental residual functional capacity (RFC) for work-related activities. RFC is the most activities the individual is still able to perform despite functional limitations resulting from all of his/her impairments. Social Security then compares that profile of capacities to the requirements of past work and other work to make its decision.

Examples of physical work-related activities include sitting, standing, walking, lifting, pushing, pulling, reaching, and manipulating objects with hands. Postural activities such as bending, squatting, crouching, balancing, kneeling, climbing, and crawling are also considered. Social Security may also consider the ability to deal with hazards and environmental exposures (temperature, odors, etc.).

Examples of mental work-related capacities include ability to concentrate; persist on task; tolerate stress; remember tasks; understand and follow instructions; interact with others (co-workers, supervisors, public); keep schedules; etc.

RFC is not what a person can do occasionally; it is what a person can do “on a regular and continuing basis … 8 hours a day, for 5 days a week, or an equivalent work schedule” in a competitive job (SSR 96-8P). Thus, a person who is only able to do part-time work might still qualify for these benefits in some situations.
There is a different standard for the children’s SSI disability program that is not covered here.

III. How Can A Medical Care Provider Help?

You can help your patient by completing disability report forms, providing narrative reports, and by keeping detailed and legible treatment records.

A. Why Should You Complete A Disability Report Form?

If you treat patients with SSD and SSI claims, you will likely be asked to complete report forms by Social Security and/or your patient's advocate. When considering whether to complete these report forms, remember the following:

1. It's Very Important To Your Patient

Your report is often the most important evidence in an SSD or SSI claim. A well-written report can help establish a legitimate claim; conversely, a poorly written report (or the lack of any report) can sabotage a legitimate disability claim, placing the patient in a difficult predicament. The stakes for the patient are high, including timely access to adequate health care and sufficient income for their (and their family’s) basic needs. Sometimes Social Security adjudicators put strict time limits on your patients to supply such evidence, so they may seem desperate.

2. It Saves You and Your Staff Time

Of course, time is at a premium in busy medical practices. Getting the documentation right the first time can often save your patient many months of delay and save you and your staff the time and effort of having to provide further documentation during appeals. Patients who are represented by skilled counsel can often make the medical care provider’s job easier by providing specifically tailored forms that can guide you through the process of properly documenting a claim under Social Security's complex rules.

3. Your Opinion Is Needed

Without the treating medical provider's well-articulated opinion, many legitimate disability claims can be lost, or delayed during lengthy appeals. Social Security adjudicators must give a treating medical care provider’s opinion much weight as long as the opinion has a proper medical basis. However, if there is no evident basis for the opinion, then Social Security can disregard it. For that reason, Social Security adjudicators often ignore:

  • Blank statements that the “patient is disabled”
  • Disability forms for other programs like welfare or workers compensation (because the disability standards are not the same)
  • References to medical records that contain no adequate explanation.

Good report forms typically ask your opinions about mental and physical limitations. Some medical care providers are reluctant to offer such opinions because physiatrists, functional capacity evaluations, or psychometric testing normally provide such documentation. However, indigent SSD and SSI claimants often lack access to them. The information is important because the treating physician might be the only informed source available to provide critically necessary information about the reasonableness of the patient’s claimed limitations.

4. Tips for Filling Out Report Forms

One legitimate way for you to document limitation is to state your patient’s claimed limitations which are reasonable and consistent with their medical condition. Social Security rules allow consideration of pain and other subjective symptoms as long as they are consistent with medical evidence. Report forms allow you to provide such information.

Ask your patients why they believe they cannot perform and sustain a full-time job. Why did they lose their last job? Are the patient's reported limitations reasonable and consistent with their medical condition(s)? If so, you can document them.

Take an extra moment to document the basis for your opinions in the form. Explain what medical condition(s) likely cause the patient's claimed limitations, and what medical evidence documents that your patient has the medical condition(s).

If the report form was requested by an attorney, a brief phone call to the attorney can help. The attorney should know the limitations that your patient claimed in his/her disability application.

B. Write a Narrative Report Documenting the Disability
If no form is available, you can submit a report that should contain the following information:

  • The length of treatment relationship and frequency of examinations: A Social Security adjudicator will typically grant more weight to a medical care provider’s opinion if there is a significant history of treatment.
  • The specialty and experience of the medical provider: Specialist’s opinions are entitled to more weight in their area of specialty.
  • Diagnosis and prognosis.
  • Signs and symptoms: The more detail here the better. Any available information on the frequency and duration of symptoms that might have an impact on a work schedule should be included.
  • Opinion about whether patient’s medical condition satisfies one of the “Listings.” Social Security has a list of impairments that it considers disabling. If your patient satisfies the requirements of one of the listed conditions, then he/she can be found disabled. Those listings are available at:

Disability Evaluation Under Social Security (from Social Security Online)

A physician can review the listing that corresponds with the patient's condition and then document in a report if the patient meets the requirements. However, if your patient does not meet the Listing requirements, he or she might still be found disabled (see steps 4 and 5 above).

  • List the patient’s claimed physical and mental limitations that are reasonable and consistent with their medical condition(s). As with the report forms, input from the patient is important in establishing claimed limitations, and you play an important role in documenting which of those are reasonable and consistent with their medical conditions.
  • Medical basis for findings. You play an important role in "connecting the dots" for the Social Security adjudicator by explaining what medical condition(s) likely cause your patient's reasonable claimed limitations, and what medical evidence documents that your patient has those medical conditions.
  • Expected duration: Social Security requires that the condition must be expected to last at least 12 months.

Examples of physician narrative reports used to document disability follow at the end of this document. See Physician Narrative Report Template for Social Security Disability Claims

C. Keep Specific and Legible Treatment Notes

Social Security Judges will often meticulously review medical records to determine if they are consistent with your patient’s claims. If treatment notes are not well documented, some judges may incorrectly conclude that the lack of detailed notes regarding a patient’s ongoing symptoms means that the patient was not having any problems.

On the other hand, easily legible treatment notes that accurately state the patient’s symptoms and signs can be helpful in documenting disability. Information about the frequency, intensity, and duration of episodic symptoms can be especially useful (seizures, migraines, bouts of severe pain, psychotic episodes, etc.). Documentation of factors that exacerbate symptoms can also be helpful (stress, physical activities that exacerbate pain, etc.).

D. The Importance Of Prompt Information

Claimants who lose legitimate disability claims due to lack of adequate documentation can face great hardship. Appeal delays have recently ballooned at Social Security. Claimants who lose at their first two claim levels may have to wait over a year for a hearing decision. During that time, we have seen claimants lose all their possessions, become homeless, or worse. This underscores the importance of providing prompt, effective medical information to help patients document legitimate claims.

Ethical and Practical Considerations

What should you do if a patient asks you to complete a Social Security disability report and you do not believe he/she is disabled? Of course, you should not certify that a person is disabled in that situation. There are still some things that you can legitimately do to assist your patient.

If your patient has some limitations, document them even if you believe they would not prevent all work. This can help prevent your patient from attempting work duties that might be medically contraindicated and which might exacerbate their medical condition. A referral to the nearest vocational rehabilitation agency might help such patients determine if any jobs might be realistically within their educational, vocational, and documented medical abilities. If other physicians also treat the patient, please indicate if they may need to be consulted in your report to get a complete understanding.

Also, document any special accommodations that your patient may need to be able to work. The Job Accommodation Network (link below) is a good resource for such information.

Resources


Disclaimer: The descriptions of the SSI and SSDI programs contained in this document are basic and summarized for brevity's sake. The complete rules are much more complex and exceptions exist to some of the rules stated. Please consult with an attorney for legal advice in any particular case.

Physician Narrative Report Template for Social Security Disability Claims

Patient: [Patient Name]
Social Security Number: [Patient Social Security Number]

To Whom it May Concern:

I am writing this report on the behalf of my patient [Patient Name]. I am [briefly state your credentials and medical specialty, if applicable]. I have treated this patient since [date started treatment] and the frequency of treatment is [state frequency of treatment].

The patient is diagnosed with [list diagnoses]. This diagnosis is supported by [state findings supporting diagnoses].

The patient's treatment has consisted of [describe treatment and response].

The patient has reported the following symptoms and limitations which are, in my opinion, reasonable and consistent with the diagnosed medical conditions. These limitations are reasonably related to the patient's medical conditions because [describe the connection between the diagnosed medical conditions and limitations].

The patient meets the criteria for Social Security Listing [indicate listing number if applicable], as indicated by [describe evidence satisfying listing requirements].

(see Listing of Impairments - Adult Listings (from Social Security Online))

The patient's prognosis is [state prognosis and opinions on ability to sustain full time competitve employment] .

Sincerely,

[Your Name]

This information last reviewed 3/29/12

 

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