What Does a Disability Doctor Look For?

In general, a disability doctor looks for medical information that shows the nature of your condition, its severity, and the limits it places on work-related activities. The exam may address physical abilities, symptoms, and test findings.

A Social Security Disability lawyer can explain why Social Security requested the exam and how it may affect your disability claim. Pilzer Klein helps clients understand the medical evidence the agency may consider during its disability determination.

The doctor who performs the exam does not decide whether you receive benefits. The Social Security Administration (SSA) reviews the doctor’s report along with your medical records and other evidence before making that decision.

The Purpose of a Consultative Examination

A consultative examination (CE) gives Social Security additional medical information when the evidence already in your file does not answer questions the agency needs to resolve. Disability Determination Services (DDS) may request a physical examination, medical test, or another type of assessment.

Social Security may schedule a CE if the records it already has do not give enough information to decide your claim. The agency may also request one when recent test results are missing or when your condition appears to have changed.

Pilzer Klein can explain where the consultative examination fits within the SSD claims process and what the request may mean for your application. The firm may also request a consultative evaluation from SSA when the available medical evidence leaves questions that could affect the claim.

What are Things the Disability Doctor Looks For?

A disability doctor looks for medical findings that help Social Security understand what your condition keeps you from doing. The exact medical evaluation depends on your medical conditions.

Pilzer Klein gathers medical evidence from treating sources because the disability doctor exam represents one part of a much larger record. Social Security considers the CE report alongside treatment notes, diagnostic tests, medical history, and other evidence before reaching a disability determination.

Your Physical Capacities and Limitations

For physical impairments, the doctor may examine strength, range of motion, gait and station, coordination, reflexes, grip strength, and mobility. The doctor may also watch how you sit, stand, walk, bend, squat, or get on and off the examination table.

If you regularly use a cane, walker, brace, or another assistive device, the doctor may document the type of device and how you use it. The exam may also include range-of-motion testing, neurological testing, imaging studies, laboratory results, or other clinical tests related to your symptoms.

Your Medical History and Treatment

The doctor may ask when your symptoms started and what care you have received since then. Your treatment history, medications, procedures, hospital visits, and medical test results can help show how the condition has developed over time.

The doctor may also ask whether treatment has changed your symptoms and what problems you still have. Your answers can help show how the condition affects you now, especially if your medical records cover a long period of time.

Your Quality of Evidence and Credibility

The examiner may note whether your statements about symptoms match the physical findings, behavioral observations, medical history, and available laboratory findings. A CE report should also explain apparent differences between what the doctor observes and the information contained in the record.

That does not make the appointment a performance or a test of whether you appear sick enough. Give accurate answers about your functional limitations, including what you can do, what causes symptoms, how long you can sustain an activity, and what happens afterward.

What is a Disability Doctor Called?

A doctor who examines you for Social Security may be called a consultative examiner or consultative examination provider. SSA uses the term medical source in its regulations. Depending on the exam, that person may be a physician, osteopath, psychologist, or another qualified health professional.

The examiner must hold a current state license and have the training and experience needed for the type of examination Social Security requests. Under 20 C.F.R. § 404.1519g, SSA may choose your medical source or another qualified provider to perform the consultative examination.

Pilzer Klein can help clients understand an important distinction: the consultative examiner does not decide whether you qualify for Social Security Disability benefits. The examiner provides medical findings and, in many cases, an opinion about work-related abilities. SSA and DDS use that information when they review the claim.

What Should You Do and Avoid Doing During Your Exam?

During your exam, the best approach is to be truthful, specific, and consistent about what your condition allows you to do. Pilzer Klein can explain what to expect before a consultative exam and why your answers and participation matter.

A few practical steps can help the doctor get an accurate view of your condition:

• Arrive on time and follow the instructions you received for the appointment.
• Bring identification, medication information, records, or other items the notice requests.
• Use your cane, walker, brace, hearing aid, or other assistive device as you normally do.
• Explain problems with sitting, standing, walking, lifting, concentrating, remembering, or completing daily tasks.
• Do not exaggerate symptoms or minimize limitations because discussing them feels uncomfortable.
• Participate in the requested physical exam or diagnostic tests to the best of your ability.

A missed consultative exam can affect a disability claim when you do not have good cause for missing it. Contact the appropriate office as soon as possible if illness, transportation trouble, or another serious issue prevents you from attending.

Talk to Pilzer Klein About Your Disability Claim

Knowing what a disability doctor looks for can help you understand the purpose of the appointment and the kinds of information the examiner may record. The Social Security Administration may use that report with your medical history and other evidence when it reviews your claim.

A Social Security Disability lawyer at Pilzer Klein can help you understand how the report fits with the rest of your medical evidence. With over 50 years of combined experience, we represent clients through the application, hearing, and appeal stages of Social Security Disability claims.

We gather medical evidence for our clients and can review how a consultative examination may affect the disability determination. There are no fees or costs if we do not win your case. Contact us to discuss your Social Security Disability claim.