When you file a claim or appeal with the Social Security Administration (SSA), it is the agency's job to obtain medical evidence before making a decision on your case. Specifically, your reviewer (claim examiner) must contact your treating physicians and try to obtain records if those records are needed in order to make a fair assessment of your level of impairment. If you do not have medical records that provide a clear overview of your disability, or have not been followed by a physician, the SSA can order that you have a consultative examination (CE) done.
The SSA may order medical and/or mental examinations. If the SSA requests that you have a CE done to assess your mental impairments, it is the agency's responsibility to pay for the examination.
Who Will Perform the Examination
Generally, Social Security prefers that your treating physician or psychiatrist complete the mental examination. There are situations, however, in which an independent physician may be used. Those situations include:
- Your treating physician chooses to not perform the mental examination
- There are inconsistencies in your record that cannot be resolved by a mental examination given by your treating doctor. This may occur if your treating doctor is the source of the inconsistencies.
- It is your preference to have an independent physician perform the examination, and you have valid reasons for such a request.
- Your treating doctor is not considered a productive source of information based on prior experience with the SSA.
Once it is decided that you should have a mental examination performed, the SSA will coordinate with a physician to set up an appointment time and place. The agency will try to get an appointment for you close to where you live.
What the Examination Will Include
SSA will order the tests and evaluations that they deem necessary in order to make a fair assessment of your disability. Therefore, these tests and evaluations will vary by person depending on the records they provided and the services and treatments they have received.
That said, at the mental examination, there are several elements that the physician must cover as required by SSA. These elements are laid out below.
Establish identity. The physician must establish your identity through proof of identity, claim number, and a physical description.
Medical history related to your ability to work. The physician will review all of your medical records available. You will be asked to provide the following information:
- the symptoms that prevent you from working
- when they started and have they have progressed
- your treatment history, and
- your typical daily activities.
Past hospitalizations, operations, and procedures.
Past and current participation in rehabilitation or supported living or other treatment, and your success or failure in those.
Past medical history. This should include other significant past illnesses, injuries, operations, and diagnosis and when they occurred.
Current medication and their effects on you.
Social and family history. This will include asking about past and present relationships with parents, family, friends, and others with whom you interact.
Relevant legal or work problems due to your impairments.
Your involvement in social activities or hobbies.
Description of your attempts to return to work and the results.
History of substance abuse, if any, and the effects on your ability to function.
Physical examination. The physician must perform a physical exam, which will include reports on:
- your general appearance and behavior
- observations as to how you got to the appointment (with whom and how), and
- any physical impairments, such as involuntary movements or problems with walking.
Mental status evaluation. The physician will make these determinations by observation throughout the mental examination. Areas that the doctor will assess includes:
- your attitude and approach towards the evaluation
- your general appearance (hygiene, dress, and so on)
- your mood
- eye contact
- your ability to communicate
- your ability to remember
- your ability to concentrate and pay attention
- your ability to think through questions and answer them
- any problems with perception
- suicidal or homicidal thoughts
- your judgment or insight, and
- your estimated level of intelligence.
Interpretation of testing done. The physician will provide clinical assessments of your performance on any psychological tests or other examinations performed.
Diagnosis. The physician must diagnose you based on the American Psychiatric Association standards.
Prognosis and recommended treatment. This will include whether you need further evaluations.
Once the physician has completed the examination, he or she must provide their clinical opinion on the following areas.
- The nature and extent of of your mental disorder.
- An assessment of your abilities and limitations based on all available information.
- Opinions on your ability to:
- carry out instructions (both simple and complex)
- complete work at a reasonable rate
- manage funds
- deal with others properly, like coworkers and the general public, and
- handle the normal pressures of work.
- Whether certain hazards should be avoided and why (like machinery, and so on).
- Any apparent discrepancies in the record and how they were resolved, and
- Whether the doctor thinks you are exaggerating your symptoms.
For an individual with intellectual impairments, the physician will also need to provide the following information:
- standardized IQ results and interpretation of those results
- consistency with educational records, and a
- description of adaptive behaviors.
Once the physician gathers all of this information and writes a report, he or she will provide it to SSA. If additional testing or evaluation is necessary, the SSA will order such testing. The mental examination report will be considered along with the rest of your record in making the determination as to whether or not you are disabled and unable to work.