The disability examiner evaluating your Social Security disability claim has informed you that you need a consultative medical examination. You know that you need to agree to the examination in order for your application to proceed, but what will the doctor be looking for?
The Green Book Guides the Consultative Exam Process
The Social Security Administration’s Consultative Examination Guide, also known as the Green Book, provides doctors with important information about:
- Social Security disability programs
- How a consultative exam may be requested
- What to look for in reviewing consultative exams
- The essential elements of the consultative exam report for specialties that often require a consultative exam
Since you have already applied for Social Security disability, and a consultative exam has already been requested, we will focus this library article on the last two important elements described above.
What Doctors Should Look for in Consultative Exams
The healthcare professional performing the consultative exam only has the authority to complete the type of exam or testing requested by the government. In some cases, this may be limited to a specific test such as an EKG, an MRI or an X-ray. In other cases it may be more comprehensive. If the physician completing the testing or exam believes that additional testing is necessary, he must get prior approval from the government before doing the additional testing.
The Essential Elements of the Consultative Exam Report
After the required testing is complete, a report should be filed that includes:
- The claimant’s identity
- The claimant’s medical history
- The claimant’s current medications
- A review of symptoms, including other symptoms the claimant might have and any negative findings that were ruled out when making a diagnosis
- The claimant’s family history
- The claimant’s social history, including the use of tobacco, alcohol, and drugs
- The results of a physical examination, including appearance, behavior, lab test results, and imaging test results
- A medical source statement, including an assessment of the claimant’s abilities and limitations
- Specific content based on the actual impairment that may or may not result in a finding of disability as described in the Green Book.
As the Social Security disability applicant, it is not up to you to preform your own exam or to write your own report. That is the job of the healthcare professional and it is, therefore, the healthcare professional who should follow the terms of the Green Book. However, since you are the one who may benefit from Social Security benefits, it is important to be aware of the Green Book and how it may impact your application.