A Message to Your Doctor (Social Security Disability)
Your patient is in the process of attempting to qualify for disability benefits from either an insurance carrier or the Social Security Administration and will need specific details when documenting their symptom’s impact on a Functional Capacity Evaluation (PCE) form. (Note: this process also can be called a Residual Functional Capacity [RFC] assessment”. It is used extensively by the Social Security Administration; it is form SSA-4734.)
The patient has provided this explanation to you, so that you can better assist them in completing the necessary forms. The patient also has taken the first step of completing the form as s/he sees symptoms impacting his/her normal daily functions. If you have a difference in opinion about your patient’s perception, please resolve the differences with the patient before completing the form.
Doctors with patients who have been injured or have Social Security disability claims are usually asked to provide evidence. But what do the Social Security people mean by "disability"? And what kind of evidence do they need from doctors?
There is no universal definition of "disability." It depends on who is defining it - Veterans administration, Worker's Compensation, ADA.
A functional capacity evaluation can be an essential tool in determining whether a patient is disabled for purposes of Social Security disability benefits. It is one of the primary reasons for SPECIFICALLY documenting the impairment a disease or illness has on a patient’s normal daily living (NDL).
An individual will be determined to be disabled if his or her impairment "meets" or "equals" the requirements of the Listing of Impairments (found in what is called the Social Security “Blue Book”. This is a list of physical and mental illnesses that the Social Security Administration (SSA) considers to be so severe that they warrant an automatic finding of disability.
However, if an impairment does not meet or equal the Listing Requirements, the patient will be determined disabled only if s/he is unable to perform work s/he did in the past 15 years and s/he is unable to do any other type of work considering residual functional capacity, age, education, and work experience. It is important to know that the proof of impairment – the documentation of this impairment – is the responsibility of the patient and his/her supporting Medical team.
An individual's "residual functional capacity" (RFC) means what an individual can do despite the limitations of the individual's impairment. The tool used to determine a patient's RFC is the functional capacity evaluation, which assesses a patient's capacity to do work-related physical and mental tasks on a regular and continuing basis--which means eight hours a day, five days a week.
A useful functional capacity evaluation needs to assess three important areas: physical abilities, mental limitations, and other non-exertional impairments and restrictions. All of a patient's impairments that are supported by medical records, even those that are not sever, should be addressed in the functional capacity evaluation since the combination of impairments may adversely affect the patient's ability to work.
1. Physical Abilities. This section of the functional capacity evaluation should describe the patient's limitations regarding physical activities. All potential activities that might be required for a work situation should be addressed: sitting, standing, walking, lifting, carrying, bending, squatting, crawling, climbing, reaching, stooping, kneeling, and so on. The patient's ability to do particular types of repetitive motions should also be considered. Please bee sure to note any necessary restrictions on the patient's physical activities. For example, can the patient lift up to 10 pounds? Over 50 pounds? And how often can the patient engage in such activity? Never? Occasionally? Frequently?
2. Mental Limitations. This part of the functional capacity evaluation should fully describe any of the patient's limitations in understanding, remembering, and following through on instructions. Also, be sure to note any limitations the patient has with respect to responding appropriately to common work situations, such as the ability to handle work pressures, receive supervision, or relate to co-workers.
3. Non-Exertional Impairments. This part of the evaluation should include information on other factors such as a patient's pain, environmental restrictions, the need for rest breaks, and any side effects of medication. When describing pain, be sure to note any objective signs of pain, the degree of pain, and the frequency of pain experienced by the patient. The evaluation should also explain whether the patient will need unscheduled breaks because of pain.
Any applicable environmental restrictions should be included in the functional capacity evaluation, as well. Must the patient avoid exposure to dust, fumes, or smoke? Can the patient tolerate heights?
The evaluation should address the patient's need for rest breaks, time off, and effects of the patient's medication. Is it likely that the patient will miss days of work because of pain or the side effects of medication? All such limitations should be fully described as they will affect the patient's ability to do work.
It is very important that the patient’s Doctors are very specific about the occupational limitations (including additional information not requested on the forms, if necessary). Also, it is important that NO ONE assume that a symptom or illness will automatically equate to functional impairment. You cannot depend on common sense to tell you who is disabled under the Social Security law. For example: with Multiple Sclerosis patients, an MRI that shows lesions does not necessarily equate to physical impairment, without the Doctor providing the actual “link” examples for that specific patient. SSA evaluators do not necessarily assume an MRI, which shows demyelinating disease, equals vocationally limiting fatigue, for example, unless a medical professional makes and explains the connection.
Here are some more examples:
1. A 48 year-old construction worker has done heavy, unskilled labor since age 16. He has a 4th grade education and a "low/normal" I.Q. He can read only basic things, like inventory lists and simple instructions. His heart condition limits him to sedentary work. He is not disabled under Social Security law unless he has an additional limitation.
2. A 38 year-old machine operator has done unskilled, medium exertion factory work since graduating from high school. A cardiovascular impairment limits him to sedentary work, and a permanent injury of the right hand limits him to work not requiring bi-manual dexterity. He is disabled under Social Security law.
3. A 61 year-old truck driver has been driving trucks all his life. But during a downturn in the trucking industry ten yeas ago he worked 18 months at a sedentary office job for his brother-in-law. Now a pulmonary impairment limits him to sedentary work. He is not disabled under Social Security law because he is still capable of doing the office job.
The Social Security Administration (SSA) defines disability as:
"Inability to perform substantial gainful activity by reason of a medically determinable physical or mental impairment, or combination of impairments, which has lasted or is expected to last at least 12 consecutive months, or end in death, taking into account the individual's age, education and work history."
The ultimate decision regarding a patient's residual functional capacity rests with the SSA, which may request a functional capacity evaluation to be performed by its own medical consultants. However, the importance of a functional capacity evaluation done by the treating physician or other health care professional cannot be underestimated. After all, it is that person who is most knowledgeable about the patient's condition and any resulting occupational limitations. The treating health care professional's functional capacity evaluation can greatly assist a patient in obtaining much-needed disability benefits.
Thank you very much for taking the time to assist your patient in this difficult process.