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Occupational Psychiatry--Independent Psychiatric Evaluations--Workers' Compensation Organizational Consultation--Second Injury Fund Evaluations C. Donald Williams MD CGP
Occupational Psychiatry--Independent Psychiatric Evaluations--Workers' Compensation
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C. Donald Williams, MD CGP The Social Security Psychiatric Disability Evaluation Basic Skills Workshop, 2001 Annual Meeting, Washington D.C. January 12, 2001 Background Congress assigned the Social Security Administration (SSA) the responsibility for evaluating applications for Social Security Disability Insurance, or SSDI . The SSA contracts with state agencies--called Disability Determination Services (DDS) in each state throughout the nation and Puerto Rico to perform these services. SSA’s headquarters are located in Baltimore, and oversees operations through ten regional offices. 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. SSDI is program for those who have paid into the system (FICA) and earned "quarters of coverage". SSI is a needs based program (like welfare). Both programs require individuals still must meet certain medical criteria to be allowed. 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. The law defines disability as the inability to engage in substantial gainful activity by reason of a medically determinable impairment which can be expected to result in death or which has lasted or can be expected to last for 12 continuous months. The disability program looks at a claimant’s remaining functional capacity to perform any type of work in the national economy. If a claimant disagrees with the initial medical disability decision he/she can file for reconsideration. If still dissatisfied, he/she can appeal to the Administrative Law Judge and request a hearing. Why
do Social Security Disability Evaluations? There
are several advantages to conducting regular Social Security Disability
Evaluations. ·
They
offer concentrated practice in conducting efficient assessments of a relatively
wide variety of patients ·
They
present an opportunity to refine conceptualization, writing and dictation skills ·
They are
an effective way of filling gaps in a schedule with guaranteed payment ·
They can
serve as an entrée to becoming involved in other types of psychiatric
disability evaluations because of contact they afford with the legal community · They present an opportunity to provide quality professional services 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 Disability Determination Services) finds that psychiatric condition may be present or there is
insufficient information for a complete disability decision. Social Security Hearings Administrative
Law Judges (ALJ) may also order psychiatric evaluations at their discretion
after hearing evidence presented at an appeal hearing.
Compensability requires total disability, i.e. the inability to perform
the functions of any job, for a period of at least 12 continuous months. 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. Some applicants are denied benefits in their initial application.
They may request a reconsideration of
the initial denial, and if that is unsuccessful they may demand a hearing by a
Social Security Hearings Judge (ALJ). No
attorneys are
involved in the first two steps, but the applicant typically retains an attorney
for the formal hearing before a judge. Attorney
fees are set by statute, and the Social Security Administration must
specifically approve attorneys before they can represent clients. In
Washington State, the
psychiatrist-evaluator is paid a nominal
fee (about $30) for record review
if the applicant fails to appear for the appointment.
Missed appointments must be reported to the Social Security scheduling
office within 24 hours.
This
amount varies from state to state. Some
states pay nothing, some states pay $10-25.
Some states are under state law to follow their “parent agency”
fee schedules, which means compensation for no shows or record review
could be considerably higher. Payment
for extra forms and review of excess medical also varies greatly from
state to state. The best
advise to those interested in doing evaluations would be to contact the
state agency (DDS) to find out their reimbursement rates. The SSA does not expect physicians to reschedule a
claimant that has missed an appointment. An additional fee is paid if the
medical file to be reviewed is 25 pages or longer. If additional forms are
requested, separate fees are paid for their completion. The
Psychiatric Evaluation A
psychiatric evaluation consists of a review of medical records provided by the
DDS, a face-to-face psychiatric evaluation of the applicant and the provision of
a written report. The report
follows a standard psychiatric evaluation format, with particular attention to
several routine questions that should be addressed in the Summary and Discussion
section of the written report. The
Disability Determination Services usually provides a suggested
outline (.pdf file, longer download).
The outline for child psychiatric evaluations is more complex, but
straightforward for those with child training. SSA is interested in facts
and evidence based conclusions as they bear upon impairments of specific
functional capabilities that have an impact on disability. Specific observation
and reporting of the claimant’s Activities of Daily Living, along with
relevant psychiatric history, and a fact based Mental Status Examination are
crucial to the exam’s utility. Particular
emphasis is placed upon utilization of the DSM-IV, as that provides a more
uniform basis for application of the relevant statues. Occasionally,
you will be asked to complete the Psychiatric
Review Technique Form
SSA-2506-BK (9-2000), either by an Administrative Law judge or by an attorney
representing a claimant. I have included a copy of the current form for your reference.
Although you will not routinely be asked to complete it, familiarity with its
provisions will help you to understand the listings requirements and the
information the examiner must have to act on your report when it is received. A
former requirement that ALJ’s use the form in cases at that level of review
has been eliminated, although they are still required to use what is termed
“Psychiatric Technique” in explaining their rulings. In general the ALJ’s are required to develop the evidence.
The ALJ’s are given discretion to adjourn, postpone, or reopen the
hearing at any time to develop further evidence before a ruling is issued.
For
our purposes it will be useful to describe elements of the form to reinforce the
importance of you (as the evaluating psychiatrist) providing data to support
conclusions in the evaluations conducted for SSA, and not simply diagnostic
conclusions based on a vaguely stated history and sketchy mental status
examination. This form (developed
in 1990, and as noted below modified effective September 20, 2000) contains
several sections, the most important of which describes symptoms or behaviors to
be checked as present or absent for the following categories of disorders.
The 12.XX numbers represent the “category” of the disorder. 1.
12.02
Organic Mental Disorders 2.
12.03
Schizophrenic, Paranoid and other Psychotic Disorders 3.
12.04
Affective Disorders 4.
12.05
Mental Retardation and Autism 5.
12.06
Anxiety Related Disorders 6.
12.07
Somatoform Disorders 7.
12.08
Personality Disorders 8.
12.09
Substance Addiction Disorders 9.
12.10
Autism and Other Pervasive Developmental Disorders Each
of these categories is provided with a specific set of criteria by which its
absence or presence is judged. For
example, for 12.03 the test is: “Psychotic
features and deterioration that are persistent (continuous or intermittent), as
evidenced by at least one of the following:
1)
Delusions
or hallucinations 2)
Catatonic
or other grossly disorganized behavior 3)
Incoherence,
loosening of associations, illogical thinking, or poverty of content of speech
if associated with one of the following; a.
Blunt
affect, or b.
Flat
affect, or c.
Inappropriate
affect. You
have a copy of the SSA form for reference and review purposes.
In general, the criteria correspond fairly closely to the DSM-IV criteria
for the listed conditions. Beginning
with September 20, 2000 an additional qualifier was allowed for each
condition—“A medically determinable impairment is present that does not
precisely satisfy the diagnostic criteria above. Pertinent symptoms, signs, and laboratory finding that
substantiate the presence of the impairment”.
The modified “Disorder” must be listed. Based
on the presence or absence of findings in the above categories, the SSA examiner
is then asked to rate the severity of impairment, describing the degree of
functional limitation in four areas of functioning.
(When a psychiatrist is asked by an attorney to conduct an evaluation for
an Appeal Hearing, he/she may be asked to complete the form and the ratings.) Significant
modifications in the “B” criteria
were introduced effective September 20, 2000, and are reflected in the following
description. 1. Restriction of Activities of Daily Living 2. Difficulty in Maintaining Social Functioning 3. Deficiencies of Concentration, Persistence or
Pace; [deleting “resulting in Failure to Complete Tasks in a Timely Manner”
effective Sept. 20, 2000] 4. Episodes of Decompensation, each of extended
duration. [This was modified to eliminate “deterioration in work or work-like
settings”.] To
satisfy the listings requirements,
the impairment must be at least "marked" or greater in two or more of
the four areas of functional limitation. [This was modified to standardize the
necessary number of “B” criteria
from 3 to 2 for Somatoform Disorders and Personality Disorders.]
An extreme rating on any of the first 3 criteria will satisfy the
listings requirements, as will a rating of “4 or more” for criterion 4.
There
are specific guidelines to be followed by the SSA in reviewing these forms.
For example, “repeated episodes of Decompensation” is defined as
meaning “three episodes within one year, or an average of once every four
months, each lasting for at least 2 weeks.”
If the episodes are more frequent but briefer, or less frequent but
longer, the adjudicator is required to use judgment to determine whether the
functional effects are comparable to those set forth in the listings.
“C”
criteria for
chronic disorders are now included in the Listings 12.02
Organic Mental Disorders, 12.04 Affective Disorders, in addition to 12.03
Schizophrenia. The “C”
criteria are considered if the “B” criteria are not met.
This modification was effected because of the realization that an
additional test of functional limitation was necessary for conditions that tend
to be chronic and disabling, but that might not meet the severity requirements
of the “B” criteria. Documentation
must show a chronic disorder of at least two
years’ duration that has caused “more than minimal limitation of ability
to do basic work activities.” An
inability to function outside a highly supportive living arrangement need only
have lasted one year, reduced from two years.
A third “C” criterion has been
added addressing individuals who are marginally adjusted and for whom an even
minimal increase in mental demands or change would be predicted to cause the
individual to decompensate. The
"Mental Residual Functional Capacity
Assessment" (Form SSA-4734-F4-SUP) is a 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: A: Understanding and Memory
(3 measures) B. Sustained Concentration and Persistence (8
measures) C. Social Interaction (5 measures) D. 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 advised that the interview is for evaluation purposes only, and that it is not for treatment. 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 to other parties. Although
in the past the SSA provided phone-in transcription service to an 800 number, in
Washington State psychiatrists have been required to provide their own transcription for the last
several years because of funding constraints, making on-site transcription
services an economic necessity if any significant work volume is undertaken. The
psychiatric evaluation is conducted according to a standard format provided by
the DDS. I find it helpful to use a
form I have developed with my word processor, as that speeds the transcription
process and helps me to remember all necessary areas of inquiry.
I have included a copy of my headings in the handouts, although you are
all encouraged to develop your own. It
is necessary 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.
The SSA appreciates timeliness, and I find that I am more efficient when
the material is fresh in my mind. 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, markedly reducing the subjective sense of being burdened.
In other words, don’t let dictation pile up. Finally,
a Social Security Disability Psychiatric Evaluation must offer diagnoses
utilizing the DSM-IV format, and comment on the degree and duration of
functional limitation resulting from the diagnosed condition. These requests are
made explicit in the evaluation request. You
will gain credibility if you avoid offering diagnoses of mental retardation in
the absence of formal psychological testing, and if you correctly place such
diagnoses on Axis II. An
evaluation of the claimant’s ability to manage his or her own funds must be
given, as this will determine whether or not a representative payee is named if
benefits are awarded. The
evaluation should also include an opinion regarding the prognosis of the
condition with treatment, and an opinion concerning the length of psychiatric
treatment that will be required. Summary of Main Points: 1.
Informed
consent is necessary; explain the purpose of the evaluation, and how the
information will be distributed. Treat
all claimants courteously. You are a neutral professional, and you are not an
adjudicator. 2.
Conduct a
standard psychiatric evaluation utilizing the DDS guidelines.
Record the primary data you obtain in the evaluation, not just your
conclusions. Your opinion must be
supported by facts and evidence to be given weight by the examiner or by an ALJ. 3.
Employ
DSM-IV diagnostic criteria in your diagnosis section. 4.
Specifically
answer the examiner’s questions regarding the claimant’s prognosis with
treatment, and the ability to manage his/her own funds. 5.
Provide
your report promptly to DDS. 6.
If you
for any reason feel that it would be unsafe for you to begin or continue an
evaluation, cancel it, and notify DDS of your reasons.
It may be necessary for the evaluation to take place within a secure
facility.
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