Winter 1999, Vol. 8, No. 2.

Psychiatric Disability

Social Security Disability Evaluations

By C. Donald Williams, MD, CGP
Yakima, WA

Background

Congress assigned the Social Security Administration the responsibility for evaluating applications for Social Security Disability Insurance, or SSDI. The Social Security Act provides for benefits to be provided for the disabled that meet certain criteria. Whereas welfare benefits are based on financial need, SSDI benefits are granted on the basis of 'impairments', which are defined in the Social Security Act. These criteria include the anticipated length of the disability and a set of accepted medical conditions causing impairments that may result in disability. They also provide a definition of the degree of functional impairment in several spheres of functioning that set the threshold that must be met in order for a person to be entitled to disability benefits.

Why do Social Security Disability Evaluations?

I have found several advantages to conducting regular Social Security Disability Evaluations.

• They offer good practice for conducting efficient assessments of a relatively wide variety of patients
  
• They present an opportunity to refine writing and dictation skills
  
• They are an effective way of patching holes in ones schedule
  
• They can serve as an entrée to becoming involved in other types of disability evaluations because of contact with the legal community
  
• They present an opportunity to provide quality professional service within the public sector with few of the problems or difficulties often associated with such work.
  

Procedural Matters

The Social Security Administration contracts with physicians to perform evaluations of individuals who have applied for benefits. Psychiatric evaluations are requested whenever the examiner (an employee of the Social Security Administration) believes that a significant psychiatric condition may be present. Social Security Hearings judges may also order psychiatric evaluations at their discretion. Compensability requires total disability, i.e. the inability to perform the functions of any job, for a period of at least 12 months.

A psychiatric evaluation consists of a medical record review, a face to face assessment of the applicant and the provision of a written report. The report follows a standard psychiatric evaluation format, with particular attention to several questions routinely posed in the Summary and Discussion section. The Social Security Administration provides a suggested outline. The outline for child psychiatric evaluations is more complex, but straightfoward.

Applicants frequently are denied benefits in their initial application. They may request a 'reconsideration', and if that is unsuccessful they may demand a hearing by a Social Security Hearings judge. No attorneys are involved in the first two steps, but the applicant may retain an attorney for the formal hearing before a judge. Attorney fees are set by statute.

SSDI benefits consist of cash benefits, which are typically greater than public assistance (welfare) benefits. Medical benefits in the form of Medicare are added after a defined period of disability.

The examiner is paid 50% of the statutory fee if the applicant fails the appointment or arrives more than 15 minutes late. Missed appointments must be reported to the Social Security scheduling office within 24 hours. An additional fee is paid if the medical file to be reviewed is more than 25 pages in length. Sometimes a form dubbed the Psychiatric Review Technique Form (Form SSA-2506-BK) is requested. This form (developed in 1990) contains several sections, the most important of which presents symptoms or behaviors to be checked as present or absent for the following categories of disorders:

1. Organic Mental Disorders
   
2. Schizophrenic, Paranoid and other Psychotic Disorders
   
3. Affective Disorders
   
4. Mental Retardation and Autism
   
5. Anxiety Related Disorders
   
6. Somatoform Disorders
   
7. Personality Disorders
   
8. Substance Addiction Disorders

Based on the presence or absence of findings in the above categories, the clinician is then asked to rate the severity of impairment, describing the degree of functional limitation in four areas of functioning:

1. Restriction of Activities of Daily Living
   
2. Difficulty in Maintaining Social Functioning
   
3. Deficiencies of Concentration, Persistence or Pace resulting in Failure to Complete Tasks in a Timely Manner
   
4. Episodes of Deterioration or Decompensation in Work or Work Like Settings…

To satisfy the listings requirements, the impairment must be at least 'marked' or greater (three or more episodes for area 4) in two or more of the four areas of functional limitation.

The 'Mental Residual Functional Capacity Assessment' (Form SSA-4734-F4-SUP) is a somewhat more detailed measure of the claimant's ability to perform functions necessary to employment. Each mental activity is to be evaluated within the context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis.

The general areas are titled:

1. Understanding and Memory (3 measures)
   
2. Sustained Concentration and Persistence (8 measures)
   
3. Social Interaction (5 measures)
   
4. Adaptation (4 measures)

The social security examiner may request this form, as may a hearings judge, or an attorney representing the applicant at the hearings stage of the appeal process.

Conduct of the evaluation

The purpose of the psychiatric evaluation should be explained to the claimant. The examinee should be advised of the limitations on confidentiality associated with their status as an applicant for SSDI. They should be informed that a copy of the evaluation would be provided to the Social Security Administration. My practice is to suggest that the applicants themselves directly request that the SSA provide copies of the evaluation to any other parties they wish to receive the report. This avoids the possibility of violating confidentiality guidelines or overlooking the obtaining of release of information forms. As a matter of policy, the physician evaluator is allowed to directly furnish a copy of the evaluation to a treating physician. Nevertheless I prefer to have the patient assume responsibility for requesting the report be sent from the SSA.

Although in the past the SSA provided phone-in transcription service to an 800 number, psychiatrists have been required to provide their own transcription for the last several years because of funding constraints.

The psychiatric evaluation is conducted according to a standard format provided by the SSA. It is helpful for the examiner to record primary data, including liberal use of quotes, accumulated during the evaluation. Specific findings on the mental status examination should be stated directly. Statements such as 'concentration and memory are grossly normal' are to be avoided in favor of facts. As an example: 'The patient was able to recall three out of three dissimilar objects at 5 minutes and was able to repeat 7 digits forward and 5 digits backward. I utilize a prepared evaluation format, which helps to avoid omissions. The evaluation should be dictated, as it is possible to produce a meaningful 4-6-page report within 5 or 10 minutes given sufficient practice and experience. For transcription purposes, I developed a formatted word processing file that contains relevant headings and saves a significant amount of typist time. One proofreading is all that should be necessary. This makes it possible to conduct the evaluation and issue a report within 24 hours. Timeliness is appreciated by the entity requesting the evaluation, and I find that I am far more efficient when the material is fresh. I make it a practice to dictate all social security evaluations within 24 hours of the interview. Usually they are completed during breaks between patients within an hour or two of seeing the patient.

Finally, a Social Security Disability Psychiatric Evaluation must offer diagnoses utilizing DSM-IV and comment on the degree and duration of functional limitation resulting from the diagnosed condition. The evaluation should also include an opinion regarding prognosis with regard to the condition and an opinion concerning the length of psychiatric treatment that will be required.

 
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