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The Advocate Study Guide

Lesson Four

Evaluating Medical Documentation

Common Sense Medical Review©

As you will remember from Lessons One and Three, the first phase of Case Development is Case Evaluation - the investigation of all appropriate evidence that you can use to build your client’s case.

Evaluating a claimant’s medical evidence is an extremely important part of the Social Security disability process, so it is a common assumption that only medical professionals can be effective Advocates. With Disability Associates’ training, this assumption is incorrect! To make it possible for individuals without medical training to be effective Advocates, we have developed a unique method that allows you to produce impactful arguments without having any medical background or training in medical terminology. We call our approach the “Common Sense Medical Review©.”

Look for the Relationship between Diseases, Symptoms and Limitations

Every medical disorder has characteristic medical signs and symptoms. Once you identify a disease’s symptoms, you can infer reasonable physical or mental limitations. Identifying the relationship between the alleged disease, its medical signs and symptoms, and the limitations it causes enables you to create an argument for a reduced RFC.

Example: Your client suffers from a multi-level degenerative disc disease, which can be the result of many different medical conditions. He complains of severe back pain on walking, bending and sitting.

You acquire a copy of the medical records, which verify both the complaint and the alleged physical limitations. You’re a careful Disability Advocate, so you look up the claimant’s specific diagnosis online or in a medical text. You discover that a person with this diagnosis may also suffer from numbness and weakness in the lower extremities.

You call the claimant and ask him, “Do you ever experience numbness and/or weakness in the legs?” He replies, “I suffer from both. In fact, I fell down a flight of stairs because of my leg weakness.”

In the above example, a little research and one question provided the starting point for your argument for a reduced RFC. All genuine medical conditions will have associated signs and symptoms. A medical sign is evidence derived from a medical test or examination that documents the condition’s existence. If the condition is severe, you can expect the symptoms to be severe and the medical signs to be clear. Usually, the more severe the symptom, the more restrictive the limitations it causes.

Symptoms cause limitations that can reduce a person’s ability to perform work. With many serious medical conditions it only requires common sense and a little reading to determine how it will limit the claimant. If you keep this relationship between a diagnosis, its signs and symptoms and the resulting limitations in mind, you’re well on your way to becoming a successful Disability Advocate regardless of your background.

Medical signs support your argument. A pathology report will verify the existence of a cancer and indicate the degree of seriousness. An X-ray can show the existence of a severe degenerative disc disease. A blood test may reveal a serious immune disorder. Signs prove the existence of an impairment and indicate its extent.

The Medical Evaluation

As you recall from Lesson One, the steps a Disability Advocate takes in processing a case are:

1. Client Interview

2. Case Assessment

3. Case Acceptance or Intake

4. Case Development

The Case Evaluation is Phase One of Case Development. To help you to better understand the medical aspects of a case, we provide two important tools:

· The Social Security Disability Guide(SSDG)

· The Systems Explorer©

The SSDG is a publication of the SSA. The Systems Explorer© is software developed by Disability Associates and provided free with our training program.

Evidence is the Key!

The quality of the medical evidence and your effectiveness in extracting information from it largely determine whether or not you win the case. Therefore we will go into depth on how to evaluate medical evidence. We have written this lesson in everyday language so that it is accessible to students inexperienced in medical record evaluation. Of course, if you are a medical professional, you’ll find this lesson much easier to comprehend. Regardless of your background, this lesson is critical to your understanding of Social Security case evaluation. Learning to evaluate medical evidence is an important skill that must be mastered to function successfully as a Disability Advocate.

Common Sense Evidence Evaluation

Evaluate medical evidence from a functional standpoint. Note how the claimant’s condition affects his/her ability to function within a normal home and working environment. Most SSA disability decisions are based on how the claimant's symptoms affect his/her ability to work. The stronger the medical support for the alleged impairments, the more likely SSA is to agree with you. Therefore, concentrate on how the claimant’s impairment might restrict his/her functionality.

Quality of Evidence

The quality of the supporting medical evidence is important. Good quality evidence addresses all alleged issues suffered by the claimant. You should evaluate both primary and secondary impairments and determine their effect on the claimant’s ability to perform work.

Supporting medical evidence should be no older than six months prior to the onset date. The evidence should show the progression and treatment of the claimant’s disorder over time, leading to the most current date. Good quality evidence should be:

· Legible

· Up to SSA standards

· Signed by the appropriate health professional.

Purpose for Evaluating Medical Evidence

Medical evidence is the documentation for your case argument. An argument for disability must hold up under close scrutiny from the DDS Examiner or Administrative Law Judge. Any medical finding that represents the claimant as functionally impaired is critical to the case.

Medical Evidence of Record

Any evidence used in the evaluation of a Social Security disability claim is referred to as “Evidence of Record.” Each claimant allegation must be accompanied by medical evidence, and SSA will request or purchase it accordingly. SSA is required to make sure that each of the claimant's alleged impairments is addressed by the medical evidence before making a decision.

On the appeal levels, the majority of evidence will already have been collected by you, the claimant or the DDS examiner. It’s always a good idea to advise the claimant to get copies of his/her own evidence, regardless of source or claim level. Both the claimant and the Advocate will have greater flexibility if the evidence is readily available. Having the evidence on hand also allows for faster case processing. When you take a case at the Reconsideration or ALJ Level, you’ll have legal access to all accumulated evidence from the initial application. You can use the medical information gathered at any level to formulate your argument on any higher level.

Sources of Medical Evidence

The claimant in may allege disability due to a physical or mental impairment or both. There’s no limit to the number of impairments a claimant can allege, so it’s common to have medical evidence from many different professional sources. A typical disability case may contain medical data from attending physicians, outpatient clinics, specialists, psychologists, hospital records, surgical summaries, outpatient records, nurse’s notes, etc. You should only request records that directly address the claimant’s primary or secondary diagnosis. The dates of the records requested should cover the period of disability.

Types of Medical Evidence

A typical disability case will contain some or all of the following types of medical evidence of record.

1. Narrative Reports from Medical Doctors

This is a common type of medical evidence of record and can come from many different types of physicians. This form of evidence usually provides specific information about the claimant's condition. The physician may also offer his/her opinion as to the extent of the claimant's disability.

2. SSA Questionnaires

A questionnaire is a pre-developed form sent to the claimant or his/her physician by SSA in order to extract information about a given medical or mental disorder. SSA often sends a questionnaire to the claimant regarding his/her daily activities or the characteristics of an alleged symptom such as chest pain.

If your client receives an SSA questionnaire, it is a good idea for you to assist in filling it out. SSA looks to use information provided by the claimant or family member as proof that the claimant can perform a certain level of activity. If the claimant indicates a higher level of activity than is alleged in his/her application, SSA will use the information to justify a denial of benefits.

3. Hospital Records: Inpatient

Inpatient hospital records are another common type of medical evidence. Most inpatient hospital records contain an admission and discharge summary which describes the claimant’s hospital stay in a couple of pages. Sending for the summary can significantly reduce the number of pages in your client folder!

Inpatient hospital records may also contain medical data such as laboratory test results, pathology reports, surgical reports, special procedure reports, x-ray findings and any important events that may have occurred during the hospital stay. Inpatient hospital records can be one of your best sources of specific medical documentation.

4. Hospital Reports: Outpatient

Hospital outpatient records can also be valuable to a case. If a claimant is treated at a hospital outpatient clinic, there may be one or more clinic notes on file. You should treat these clinic notes the same as any other doctor's report.

Note: Never request medical records that have nothing to do with the claimant’s alleged impairment!

5. Consultative Examinations

A medical examination, lab test or any other procedure ordered and paid for by SSA is referred to as a Consultative Examination. SSA only orders these examinations when the medical evidence of record is insufficient or too old to establish the claimant's current medical status.

You have the option on a consultative examination to use SSA's medical source or the claimant’s family doctor. We suggest you use the claimant’s family physician if he/she is a strong believer in the claimant’s inability to work as a result of his/her impairment. If you feel that the examination isn’t necessary for a favorable decision, point this out to SSA. However, if SSA orders the claimant to attend a consultative examination, make sure he/she goes. Otherwise, SSA will deny the case based on the claimant’s failure to cooperate.

6. Special Procedure Reports

Usually found in hospital records, Special Procedure Reports include special tests like angiography, CAT scans, biopsies, etc. These types of reports can be invaluable in arguing a case because some of them are capable of pinpointing very obscure evidence supporting the claimant's allegations. Incorporate any abnormal findings into your argument.

7. Military or VA Hospital Reports

Treat information from these facilities the same as any other hospital evidence of record. Look for the same findings in these reports as you would in any other hospital report.

8. Activities of Daily Living Reports

A DDS Examiner sends out an Activities of Daily Living (ADL) questionnaire to a friend or relative asking them to describe the claimant's daily functioning. The purpose is to see if the claimant is as restricted as claimed. If this third party report is inconsistent with the claimant’s allegations, SSA will deny the case. SSA must accept third party reports as a means of determining level of limitation. Thus, ADL reports are extremely important. However, if used properly, they can help you to win cases.

9. Chiropractic Reports

SSA does not consider chiropractic reports to be an acceptable form of medical evidence. However, you shouldn’t ignore this source. Although chiropractic reports aren’t allowable in establishing a disabling condition under SSA regulations, they can be used as supporting evidence if the condition has been previously diagnosed by a medical doctor.

We recommend using chiropractic reports to support back impairment claims previously diagnosed by an MD - especially when there’s little other supporting evidence on file. Chiropractic reports also show the claimant’s efforts to attain relief, which suggests a chronic disorder with long term symptoms.

IMPORTANT! Medical Record Confidentiality

As the claimant's authorized representative, you have as much right of access to case information as the claimant himself/herself. Federal law clearly states that all case information is to be kept strictly confidential and should not be available to anyone except those with authorized access to these materials. Even if you break the confidentiality rule unintentionally, SSA could bar you from performing as a representative. So be careful! Do not share information about a claimant or his/her case with anyone outside of your firm. Also make sure that your staff understands and abides by SSA’s confidentiality rules.

Key Point Extraction™

Key Points are those findings within the body of medical evidence that clearly support an alleged limitation. Extracting key points from the medical evidence can be a relatively simple procedure if you follow a few rules of thumb:

A. Medically Substantiate Disability

Consider all medical findings that substantiate disability to be important elements of your argument for a reduced RFC.

B. Use Only Evidence that Supports Your Case

Avoid evidence that is not related to the claimant’s primary or secondary conditions unless the additional impairment it documents causes additional physical or mental limitations. Use any and all restrictive symptoms that are documented with medical evidence. If a piece of evidence does not support or strengthen your attempt to show the claimant as totally disabled, don’t include it!

Examples of restrictive symptoms to use as key points in the case are:

· Pain

· Fatigue

· Dizziness and Vertigo

· Loss of physical coordination

· Inability to ambulate

· Blurred vision

· Muscular weakness

· Memory loss

· Lack of concentration

· Inability to interact with others

· Extreme hostility

Individually or collectively the above symptoms can support a more restricted RFC, improving your chances of winning the case.

C. Use Direct Quotes from MDs

Don't hesitate to use doctors’ quotes, either verbal or written, that support your conclusions.

Example: Dr. Good states that the claimant should not be on his feet for more than an hour a day because of his impairment.

Statements like this are powerful tools for restricting the claimant's RFC.

D. Be Mindful of the Dates of the Medical Evidence

Review all available evidence for the time period that the claimant alleges as the period of disability. Unless there's a DLI in the past, you should acquire medical reports from the onset date to the present. “Present” refers to evidence dated within three months of the date of the current disability decision. If the case has a DLI in the past, you should request evidence from the alleged onset date to the DLI date. A person with a DLI in the past must be found disabled on or before the DLI date in order to receive benefits.

Steps for Extracting Evidence

Efficiently extracting key findings from the medical evidence is a step-by-step procedure, and is only the beginning of the case analysis process. Once you’ve identified and summarized the key medical facts, you evaluate the vocational evidence. Then you bring the medical and vocational data together to form your argument on behalf of the claimant.

To make this process easier to understand, let's create a hypothetical case on behalf of a fictitious Mr. Katz. As we go through our general discussion, we will use Mr. Katz’s case as an example of how to extract the key medical findings using the step method. Then we will summarize both the findings and the steps at the end of this lesson.

Step One: The Telephone Interview, Case Assessment, Acceptance and Recon Development.

As outlined in Lesson One, at the beginning of a case you interview the claimant to acquire specific case information. Use this interview to make sure the case is worth taking. If there are no red flags to make you drop the case immediately, do a case assessment using the Olivia© case assessment system located in your account. If results are positive, formally accept the case.

After determining that the case is worth accepting, you move to Case Development Phase One: Case Evaluation. Discuss the case further with the claimant to extract key points that will help you to better understand his/her circumstance. In the following example using Mr. Katz, we highlight the important information to give you a feel for useful data to collect in your client interviews.

Mr. Katz states that he suffered a heart attack on 10/01/09 and has not been able to work since. He applied for benefits on 2/01/10 and was denied four months later on 6/1/10. Thus, a total of eight months has passed since the onset date of his impairment. He asked you to represent him on 7/01/10, which is within his sixty-day limit for applying for a Reconsideration Appeal.

The claimant also states that he continues to suffer from chest pain on exertion and an inability to stand and walk for more than thirty minutes without pain and prolonged rest. He feels physically weak and he has a high level of anxiety and fear for his financial future.

Since his heart attack, he has been seen by two doctors: Dr. Jones and Dr. Smith. He has been hospitalized twice, once at the time of the heart attack and again six months later for unstable angina. Both hospitalizations were at St. John's Hospital. The claimant also states that he is fifty-one year old, has eleven years of education and has worked for fifteen years as a carpenter.

Analysis of Example Information

In the phone interview you learned that Mr. Katz's primary diagnosis is heart disease. The onset date is 10/01/09 - the date of his original heart attack. You also found out when he applied for benefits (02/1/10), the outcome (denial) and the date of the decision (6/1/10). You discovered that the claimant is now applying for Reconsideration and that he's within the sixty-day appeal limit.

You've also learned from the claimant that he has a new complaint (symptoms) that if medically documented, could be used as additional ammunition in your case argument. This additional ammunition is used to further reduce the claimant's perceived RFC at the Recon decision level. The claimant should provide the name of a doctor that he has seen for the new allegation. If there is no new doctor, look for supporting evidence within the existing client records. Since the case is at the Reconsideration Level, you can petition SSA to get any new evidence you deem necessary at no cost, or you can save time by requesting the evidence yourself direct from the client's medical source.

Step Two: Case Evaluation: Extracting Information from the PDN

Assuming that you accept the case at an appeal level, the claimant will normally have his/her Personalized Denial Notice (PDN), which indicates the reason for the denial decision. Get a copy from the claimant to quickly determine why the case was denied and at what step in the SA process.

Mr. Katz’s PDN reads as follows (key information is highlighted):

“Claimant is a 51 y/o individual who has alleged disability due to an acute myocardial infarction. The evidence shows a significant impairment that does not meet or equal the listings. The evidence also shows that despite his impairment, he is still capable of performing work of a light RFC. It appears that the claimant is capable of returning to the duties of his past work as a carpenter. Therefore, we have considered his age of 51, education 11th grade and his remaining ability to perform work in determining that he is capable of performing his past work. The cited Voc Rule in this case is 202.12, which directs a decision of not disabled. It has been determined that the claimant is capable of performing past work and accordingly he is found not disabled as defined by law.”

Analysis of Mr. Katz’s PDN

The PDN (also known as the Form 4268) has given us a lot of useful data. It tells us the primary diagnosis is a myocardial infarction. The PDN also takes us through Step Five of the Sequential Analysis (SA) process, which indicates he is capable of performing his past work. The DDS Examiner has given Mr. Katz a light RFC. Apparently, the claimant's past work must carry an SSA-defined exertion level of light, resulting in the claimant’s assigned RFC.

The PDN has told us the case was denied at Step Five of the SA process. Our job is to argue that in actuality the claimant has a lower RFC than that given by the SSA and that he is not capable of performing his past work. If we want to win the case, we must also argue that he cannot do other less demanding work.

This sample PDN has also introduced a new concept called the Vocational Rule 202.12. We cover Vocational Rules in depth in Lesson Five.

Step Three: Case Evaluation: Evaluating the Medical Evidence

As discussed in Lesson Three, the Whole Body Principle is critical to your case development. Accumulate all appropriate medical evidence from the sources discussed above:

· MD Narrative Reports

· SSA questionnaires

· Inpatient and Outpatient Medical Records

· Consultative Examination Results

· Special Procedure Reports

· Military or VA Hospital Reports

· ADL Reports

· Chiropractic Reports

Be sure to review all information carefully.

You have just received Mr. Katz's medical information from the DO. It includes a number of reports from Dr. Smith and Dr. Jones, as well as records from St. John's Hospital. The St. John's Hospital records tell us what occurred during the claimant's hospitalization for an acute heart attack. They also include results of a physical exam, EKG, and lab test. The tests are indicative of a fifty-one-year-old man in acute cardiac distress. He was treated appropriately and recovered without complication. There were no surgical procedures. A cardiac catheterization was done and showed partial blockage of a major coronary artery. Mr. Katz was placed on nitroglycerin for chest pain and was discharged six days later in stable condition.

Mr. Katz was hospitalized at St. John’s six months after his heart attack for unstable angina (chest pain). He was sent home four days later with nitroglycerin and instructions to rest.

Dr. Smith is Mr. Katz's cardiologist. He has supplied a narrative report on the claimant's cardiac condition since his hospitalization in 2009. Dr. Smith states:

“Mr. Katz suffered an acute MI and since that time he has been experiencing chest pain upon exertion. Mr. Katz has complained of occasional chest discomfort that is relieved by sublingual nitroglycerin tablets.

“Although it has been months since his original heart attack, Mr. Katz is not as yet able to return to any type of work activity. The patient continues to suffer from exertion-related chest pain that is giving us some concern. We are slowly increasing his exercise tolerance, but we do not want to push him too hard due to his poor physical conditioning. Mr. Katz has also shown some signs of situational depression that may be associated with his current financial problems.”

Dr. Jones has taken care of Mr. Katz for years as his family doctor. Dr. Jones' report gives essentially the same information as Dr. Smith's concerning Mr. Katz’s heart condition. However, Dr. Jones' report also alerts us to a medical problem that we previously knew nothing about. According to Dr. Jones, our claimant has a history of diabetes. The claimant’s diabetes is insulin-dependent and has caused poor circulation and pain in both lower extremities. Dr. Jones also confirms the claimant’s continuing problem with chest pain.

Analysis of Mr. Katz’s Medical Evidence

The St. John's Hospital records are important because they establish the claimant’s diagnosis and the seriousness of the underlying condition. The heart catheterization report showed a significant blockage of a coronary artery, which verifies the claimant's primary diagnosis of coronary artery disease. There is little else in the way of outstanding findings, but these records support the validity of the physical limitations alleged by the claimant. The report also establishes the onset date of this claimant's disorder.

Dr. Smith’s report yields facts we were not aware of from previous records. Dr. Smith has verified Mr. Katz's continuing problem with chest pain and poor exercise tolerance. He has also given a written opinion concerning the patient's inability to work and has added a new diagnosis of situational depression. This additional diagnosis supports the claimant's allegation of anxiety associated with his concerns about the future.

Note: Anxiety and depression are mental states that may result from a claimant's physical condition having an adverse effect on his/her mental health. This type of finding can further reduce the RFC.

We have learned from Dr. Jones' report that Mr. Katz has diabetes accompanied by poor circulation and pain in the lower extremities. This information can further reduce the claimant’s RFC.

Step Four: Case Evaluation: List and Summarize the Evidence

Summarize the medical findings in preparation for creating your final argument. This is a good habit to get into when reviewing any disability case because it makes it easier to recall the key facts as you write your argument.

Here’s the summation of some key evidence found in Mr. Katz’s case:

Claimant suffered an acute myocardial infarction (heart attack),
EKG, lab and cardiac catheterization reports verify the condition
Onset date: 10/01/05, which is the day of the heart attack
Mr. Katz also suffers from diabetes, poor circulation and pain in both legs
Claimant has chest pain on exertion
Dr. Smith, Mr. Katz’s cardiologist, states claimant is unable to work due to unstable chest pain
Mr. Katz alleges that he cannot stand or walk for extended periods of time due his chest pain, weakness and pain in legs
Mr. Katz also alleges that anxiety makes it difficult to concentrate
The case is at the Reconsideration Appeal Level

· SSA has determined that Mr. Katz can do his past work

This is not an exhaustive list for Mr. Katz’s case, but it gives you the idea of how to summarize your key points.

Step Five: Case Evaluation: Identify All Physical & Mental Limitations

To accomplish Step Five, you must take the time to learn about the disease state(s) you’re dealing with in each case. You don’t have to understand every aspect of every disease you encounter. Focus on the signs and symptoms that coincide with those alleged by the claimant. It is these limitations and not the disease that we use to argue for a reduced RFC.

We recommend that you read a little on each of a case’s alleged impairments. This will help you in your evaluation and will shorten the time it takes you to produce an argument.

You can access excellent sources of information through the Program Syllabus. Good resources include:

· Merck Manual Online

· Social Security Disability Guide

· Any medical text that discusses disease states in layman's terms

These medical references will help you to identify physical or mental limitations that are normal for a particular disorder. It is more important that you understand how a disease can physically or mentally restrict a person's functioning than it is to understand the disease itself. If you understand how a disease can physically or mentally restrict an individual and you can prove that the restrictions are reasonable given the case medical evidence, you have the ingredients of a winning argument.

How to Use the Merck Manual

The Merck Manual is a diagnostic reference book widely used by consultants, medical professionals and many Social Security-related agencies. The text is broken into segments, each covering a category of disease. To use the manual, take the name of the disease state, such as “myocardial infarction, lay term heart attack”, and turn to the index in the back of the book. Look up the diagnosis (they are listed in alphabetical order). The number that appears by the name of the disorder is the page number where you will find information about the disease. The Merck Manual provides a wealth of information about almost any disease state. It also provides information on common signs and symptoms associated with disease states.

Understanding Signs

A medical sign is evidence derived from a medical test or examination that documents the condition’s existence. Medical professionals use signs as a means of formulating diagnoses. For the Disability Advocate, signs reinforce an alleged disorder’s existence. If a person alleges a disorder and claims symptoms but has no supporting signs, he/she will not be found disabled.

If a doctor took a sharp needle and used it to stick Mr. Katz in his lower extremity, he/she would be looking to extract a medical sign. If Mr. Katz did not feel the needle, this is a sign that he may be suffering from severe nerve damage in that area. Mr. Katz has a secondary diagnosis of diabetes. The needle test indicates a neurological reduction that may be due to peripheral neuropathy. Peripheral neuropathy (destruction of nerves) is a sign of a progressive diabetic condition. This sign provides an important hint as to the extent of Mr. Katz’s diabetes. If Mr. Katz felt the needle, the sign would indicate a less serious diabetic disorder – unless, of course, there were other serious signs.

A Quick Review of the Steps to Building Your Case

In the Case Assessment, you allow the claimant and the medical evidence to tell you what the relevant restrictions are. In the Case Evaluation, which is the first phase of Case Development, you must gather data to prove that the alleged restrictions are reasonable and consistent with the claimant’s alleged condition. Finally, in the Argument, which is the second phase of Case Development, you present the restrictions and supporting evidence to argue for total disability.

Note: If a claimant has several severe impairments, each of which causes restriction, combine their effects into an even stronger argument for limitation.

Mr. Katz is suffering from a number of diseases, each of which can potentially cause a number of physical and mental limitations. It is these limitations, not the disease itself that we use to argue for a reduced RFC. We have found that Mr. Katz’s alleged restrictions are indeed reasonable and supported by medical evidence. In order to win this case, all we need do is compile the evidence in a convincing argument for a reduced RFC. If we successfully reduce Mr. Katz’s RFC to less than sedentary, the case will be allowed, as long as SSA agrees with our findings.

Summary

The following is a summary of the five steps outlined above for building a disability claim. Each step will help you to gain key medical evidence.

Step One: Initial Interview, Assessment and Acceptance:

· Interview client for relevant information and potential for case success

Step Two: Case Development Phase One: Case Evaluation: PDNs

· Extract information from the claimant’s PDN if available

Step Three: Case Development Phase One: Case Evaluation: Evidence

· Accumulate all appropriate medical evidence from all available sources

Step Four: Case Development Phase One: Make a List

· List key findings in the case in preparation for creating the argument

Step Five: Case Development Phase Two: Create the Case Argument

· After a thorough review, create your argument using the key evidence

Lesson Five Preview

Before creating your argument, you should do a quick review of the claimant’s vocational history. Evaluating work history involves a process called Vocational Analysis. In Lesson Five we’ll introduce you to the Vocational Analysis process. You will use this process in conjunction with the medical evidence to create the final argument on claimant’s behalf.