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Diagnostic Restrictions Guide

Introduction to the DRG

The Diagnostic Restrictions Guide (DRG) has been created as a means of introducing the disability representative to some of the more common physical and mental limitations that can be caused by a given disease state. This new on-line text will be especially helpful to those representatives who have not had formal training in a health field. The DRG is divided into what is known as systems categories. This means that instead of trying to define limitations for each individual disease, we place the most commonly seen diseases into a specific category and discuss how that category of diseases can affect an individual's physical or mental capabilities.

Each disease category has a list of common diagnosis associated with it. This list will give you some idea of the types of disorders which fall into a given category. You will also find a narrative discussion of the most common physical and mental limitations which can be found in a particular category. We will point out commonly used supportive evidence used in the evaluation of certain disease states. This sample evidence is extracted from a client's medical data. We will also discuss special disease characteristics as they pertain to disability.

Be aware that a limitation will not necessarily be found in a disease state even if the limitation usually occurs. You must review each case individually and use your common sense to extract what is useful to the client's case. If the claimant alleges a given restriction, you may take him at his word. However, always seek medical findings which will support the claimant's alleged limitations. If the evidence shows medical findings which should cause a limitation but the claimant has not alleged it, assume the limitation exists and claim it on behalf of your client.

Remember, you are the client's advocate and it is your duty to see that all limitations real or imagined are considered. Most claimants never express the full restrictive nature of their impairments. Therefore, it is up to you to make sure that all reasonable restrictions are considered. A reasonable restriction is any physical or mental limitation which is supported by the medical evidence.

This text is further divided into a child and mental impairment subsections. All information in this text can be considered to be characteristic of both adult and child cases unless the information is designated in the child only subsection.

Identifying a disease:

Lets say that you have just opened your first case and the disease the claimant is suffering from is called a CVA or cerebrovascular accident. You have never taken a medical terminology course and you have no idea what a CVA is. What do you do?

We have recommended the Merck Manual be purchased prior to taking cases and this is the reason why. Using the Merck Manual, you need only to turn to the rear of the text and look up in alphabetical order the terms cerebrovascular accident. The manual will give you a page number in dark lettering. Turn to this page for a complete discussion of a cerebrovascular accident. What you will find at first glance is that a CVA is also known in lay terms as a stroke.

You should also note that a CVA is listed in the neurological systems category which tells you what system to turn to in the DRG. Even though the Merck Manual discussion can be technical, you will learn valuable information about a particular disease if you read it.

The key to winning disability cases does not lay in understanding the technical aspects of a disorder. Winning disability cases is determined by how well you understand how a particular disease can limit an individual. Learn just enough about the disease state to unable you to argue with conviction the limitations caused by the impairment.

What is a systems category?

In medical science, the human body is divided into what is known as body systems. Each system represents a major physiological function within the living organism. The heart for example is a part of the major system known as the circulatory system. The brain is the primary organ within the neurological system, and so on. We have chosen to use the systems categorizing method because it is far easier to identify restrictions by system than by specific disease. Assuming you are not familiar with the body systems, we have listed them below. If you encounter a disease and are unaware of how it might restrict activity, you can turn to the DRG and find examples of general limitations seen in diseases of that category. This approach will at least give you a starting point for evaluating any claimant disorder.

Systems Categories

Musculoskeletal
Special Senses and Speech
Respiratory
Cardiovascular
Digestive
Genitourinary
Hemic and Lymphatic
Skin
Endocrine
Multiple Body Systems
Neurological
Neoplastic
Mental

This DRG text is also arranged according to the above body systems and will list and discuss a number of common diseases seen within each category.

Supportive Evidence:

The DRG will list the types of supportive evidence you should seek when trying to evaluate a given disease state. Generally, medical evidence (with the exception of special test and lab work) is written in lay terms. You will be able to understand most of what you are reading even if you are not familar with medical terminology. We will attempt to explain some of the more common lab and special testing procedures in order to enable you to review evidence more confidently.

Age-Related Activities:

When evaluating cases involving children, you will learn that there are no work issues to consider. This means that when you argue these types of cases, you cannot use vocational factors as in most other case types. In a child disability case (under age eighteen), you must try to prove that as a result of the impairment the child cannot perform age-related activities. In a child case this is straight-forward. If a child is ten years old and is unable to tie his shoes or dress himself as a result of his impairment, chances are this child is suffering from a disabling condition.

The disabling condition may not meet the specifics of the so-called Listings, but the condition still prevents normal age-related activities. The activity itself can be anything that is age related. The following is a list of restrictions that are considered important in the eyes of the Social Security Administration.

The following is a list of the most dynamic restrictions seen in both child and adult disability cases. Look for these types of restrictions in all cases you review. The claimant has:

1. Decreased fine or gross motor movement of the hands.
2. Significantly reduced coordination.
3. Limitation in movement of two or more joints.
4. Gait disturbance (walking problems).
5. Inability to perform age-related hygiene tasks without assistance.
6. Inability to avoid environmental hazards (age-appropriate).
7. Significantly reduced ability to communicate in speech or manner.
8. Uncontrollable antisocial behavior.
9. Uncontrollable phobias (fears).
10. Chronic disorientation.

The foregoing symptoms are just a few of the many restrictions which can occur as a result of an impairment. Again, these restrictions can be age related and should be noted in both adult and child disability claims.

Child cases are the only cases that currently use only age-appropriate restrictions as the primary means of determining disability. This is because kids don't usually have a work history so vocational analysis would make no sense. Therefore, if you are dealing with a case on an individual under age eighteen, determine if the impairment restricts normal age related activities or behaviors.

Widow Cases:

Lets assume that we have a case on a 51 y/o (year old) widow who has been previously denied benefits because she does not meet or equal the listings. New SSA regulations now allow us to review widow cases in the same way that all other adult cases are reviewed. In other words, we must now consider the widow's ability to perform work.

In this example, the widow's only impairment is morbid obesity with a weight of 320 lb. (pounds) at five foot three inches in height. She complains of joint pain and difficulty walking. Because she does not have an additional significant impairment, according to SSA she would not meet the medical listing criteria for obesity set forth by SSA. According to SSA, all she has is excess weight. To reverse SSA's opinion, you could attempt to prove via the medical evidence that this claimant cannot ambulate (walk) for more than a few minutes due to her weight and joint pain. It is quite reasonable to argue this point because joint pain is common with morbid obesity. However, for the joint pain argument to be accepted by SSA, there must be both physical evidence and X-ray findings that show a relationship between the joint pain and a disease state within the painful joint. In other words, the obese client must also have evidence of at least mild arthritis in the restricted joint. Always look for additional impairments to strengthen your argument for a reduction in a claimant's ability to perform any given activity.

The claimant is the best source for these additional allegations. By paying close attention to the claimant's symptoms and allegations, you can identify a multitude of physical or mental restrictions. Symptoms that are real will often lead you to an undiscovered or less serious disease state which is the underlying cause for the symptom. These additional disorders can then be used to further restrict the claimant's ability to work leading to an allowance determination. In this example, obesity with joint pain as a result of even mild arthritis could lead to an allowance determination by SSA.

Pain:

Pain is the most valuable subjective symptom in your arsenal of limiting factors. When pain is alleged, use it to your client's advantage. Discuss how the pain limits the claimant and don't be afraid to lay it on thick. Always make sure that the claimant's alleged pain is being caused by a medically documented impairment. Don't just say the claimant is in pain and leave it at that. Discuss the reason for the pain, where it is located, the efforts made to reduce it and most importantly, how it affects the claimant's ability to perform work.

Contralateral Impairments:

A contralateral impairment is a condition whereby a claimant has a similar impairment in two locations on the opposite side of the body. An example of a contralateral impairment would be a claimant who has a club right foot on the right side and a deformity with missing fingers of the left hand.

If the person suffering from a contralateral impairment is reasonably functional despite the impairments, the case may be denied. You must argue that due to the claimant's contralateral limitations, he could not realistically find gainful employment. You would of course, detail the limitations in activity and movement caused by his impairments using the common sense approach as your primary guide. It doesn't take much medical knowledge to explain how this type of condition can prevent work activity.

Multiple Impairments:

In a multiple impairment condition, you are working with a claimant who is suffering from a number of serious medical disorders. This can range from two to thirty different disease states all of which can limit the claimant in a number of ways. Multiple impairments are common, but you must learn to distinguish between those which will result in an allowance and those that simply cause discomfort.

A rule of thumb is to choose those conditions that are the most serious. Serious disorders are usually most limiting in there effect on the claimant's ability to work. You can also argue physical and mental impairments together or separately. Whatever it takes to formulate the strongest argument on your client's behalf is the approach you should take in choosing impairments. A multiple impairment (more than one disease), can be contralateral and occur on the same or opposite side of the body.

Less Than Sedentary Work :

As you begin your career as a disability representative, you will discover that the majority of your clients will be younger individuals. That is, most claimants will be forty-nine years of age or younger. Because of the claimant's young age category, you will be required to lower their RFC to less than sedentary work in order to achieve a logical allowance determination. Therefore, it is especially important that you are aware of the requirements for a less than sedentary RFC. The DRG information can help you develop your argument for this RFC level.

Requirements For Less Than Sedentary RFC:

The requirements for less than sedentary work are met if you determine that your client is unable to lift more than 10lbs maximum and is unable to stand or walk for more than two hours per day, and at least one of the following:

1. The individual requires a cane, walker or other assistive device in order to do minimal ambulation (walking).

2. The individual cannot bend at the waist without significant pain and discomfort.

3. The individual cannot do prolonged sitting without experiencing pain which requires frequent postual change for relief.

4. The individual must have full use of his/her upper extremities in order to perform sedentary work. The RFC would be limited to less than sedentary if the claimant is limited in fine motor movements such as handling, fingering or feeling in either hand. The RFC is also reduced if the claimant is unable to use or has a significant reduction in the use of an upper limb due to any impairment.

5. Poor close vision. An inability or significant reduction in claimant's ability to read due to poor vision.

6. Significant hearing loss. Most sedentary jobs do require that a person be able to hear at least normal conversational speech.

MENTAL
Residual Fucntional Capacity

Less Than Simple Unskilled Work:

The terms simple and unskilled are indications of the mental capacities required to perform a given type of work. When you see these RFC terms in a disability case, they are referring to claimant's remaining mental capacity.

An individual is limited to less than simple unskilled work if due to his impairment, the claimant is unable to understand and remember very short and simple instructions. The claimant must also be unable to carry out those simple instructions without special supervision. If an individual is markedly restricted in the above functional area, that person cannot be reasonably expected to perform any type of work. If the claimant is only moderately restricted in his ability to understand, remember and carry out simple instructions, we may want to identify other moderate mental restrictions in order to strengthen our argument. See sample mental RFC form 4734 in Lesson Four of your Study Guide. The mental RFC form 4734 gives you an array of restrictive possibilities to use in your argument.

Marked vs. Moderate Restrictions:

Using the medical evidence, you will be able to determine whether a claimant is moderately or markedly limited by the impairment. All mental case evidence will contain descriptions of claimant's functional level during the period he/she was suffering from the impairment. Using your common sense and noting how claimant's symptoms are described by the evidence, you will get a feel for the intensity of the claimant's restrictions. The DRG will also supply specific information such as IQ levels, etc.

Objective Evidence:

Objective evidence is any medical finding which can be observed and reproduced. This form of evidence is the most relevant to any disability case. This type of evidence can be seen or reproduced by independent sources and is therefore considered to be substantive.

Examples of objective substantive evidence are results of a doctor's physical examinations, lab tests, x-ray findings, scans, biopsies, EKGs, etc. Always try to find as much objective evidence to support your case argument as possible. The more objective evidence you have to support your position, the more likely you are to win.

Subjective Evidence:

Subjective evidence is defined as any finding which may or may not be reproducible and is dependent upon feedback from the claimant or other parties. All symptoms alleged by a claimant represent subjective evidence. In other words, this is what the claimant says, which may or may not be true. Always try to support the claimant's subjective allegations with some form of objective evidence or SSA will simply ignore the weight of the allegation. Even the allegation of pain must be substantiated with some type of objective finding denoting the existence of an impairment which is causing the pain.

Medication Side Effects:

Often you will argue a case on an individual who is under current therapy. If this therapy involves large doses of pain medication or other drugs which alter the claimant's mental or physical state, this is relevant to the claimant's RFC. If claimant is under treatment with a drug that causes adverse symptoms of any type, use this as an additional restrictive factor in your argument. Point out how the drug affects the claimant and describe the limitations induced by the medications. If the claimant must be on medication to control the disease, you may win the case based on a reduced RFC caused by the effects of the drugs used in therapy.

Common Medical Terms:

Disability Associates offers a medical terminology home study program for this with little or no knowledge of medical terms. To fine out more, click on Med Course.