Introduction

In order to qualify for SSI or Social Security Disability benefits, a claimant must establish the inability to work. Social Security has published regulations that provide a framework for proving that a claimant is unable to work.

Traditionally, Social Security has used many rules that let a claimant establish a claim if he or she suffers from a serious physical impairment that causes exertional limitations.

Recently, Social Security provided guidelines for establishing a claim based on mental impairments.

As discussed below, full documentation of a patient’s impairments can greatly improve a patient’s chances of qualifying for benefits.

The Listings

The Social Security regulations provide that if a claimant can satisfy the severity requirements for one or more of a list of specific impairments, the claimant has proven an inability to work without the need to address specific job skills. These are called "the listings."

After consulting psychiatrists, Social Security created 8 diagnostic categories for the listings:

1. Organic mental disorders;
2. Schizophrenic, paranoid and other psychotic disorders;
3. Affective disorders;
4. Mental retardation;
5. Anxiety disorders;
6. Somatoform disorders;
7. Personality disorders; and
8. Substance addiction disorders.

Each diagnostic category contains a list of specific impairments. Most listings have two requirements – the diagnostic criteria (roughly parallel to the DSM-IV criteria), and functional severity requirements. Deciding functional severity normally means deciding whether the claimant has a "marked" limitation in two or more broad categories: activities of daily living; social functioning; concentration, persistence, and pace; or deterioration or decompensation in work or work-like situations. Social Security defines "marked" as more than moderate, but less than extreme. A more helpful way to define "marked" is the bottom 2% of the general population.

How to use this to help your patients:

All too often, a patient is diagnosed with a mental impairment, such as major depression, and the practitioner assumes it is obvious that the patient has problems in the functional areas listed above. A description of the patient’s functional limitations, using the regulatory language, would be an enormous help in the patient’s Social Security claim. For example: "Mr. Madison continues to suffer from major depression, which causes him marked problems relating to his family and in other social settings, and marked inability to motivate himself to take care of appropriate activities of daily living."

Ruling 96-9p

In addition to regulations, Social Security periodically issues "rulings" to explain its policy. One key ruling for mental claims is Social Security Ruling 96-9p. This ruling contains specific language for finding a claimant disabled by mental limitations.

It provides that 4 mental activities are generally required by competitive, remunerative, unskilled work:

1. Understanding, remembering, and carrying out simple instructions.
2. Making judgments and simple work-related decisions.
3. Responding appropriately to supervision, coworkers, and usual work situations.
4. Dealing with changes in a routine work setting.

If a patient is only able to maintain any one of the above 4 activities in a sheltered workshop-type situation, or not at all, the patient has suffered a "substantial loss" of that ability. Such a patient should be found disabled.

How to use this to help your patients:

It is very common for mental patients to suffer from a complete lack of the ability to maintain one of the above abilities. The mere use of the above language to describe a patient’s limitations would help that patient’s Social Security claim. For example: "Mr. Madison continues to respond with an inappropriate amount of anger to authority. He is not yet able to handle supervision in a full-time work environment."

GAF (Axis V) Scores

The GAF score is a common tool for evaluating and tracking the overall psychological functioning of a patient. It also has significance for Social Security claims. Social Security relies upon GAF scores to see whether a physician believes that the patient is capable of working. This is primarily due to the definition of a GAF score of 41-50 – "serious symptoms," or any serious impairment in occupational functioning. The DSM-IV provides that an example of a GAF score of 41-50 is the inability to work.

How to use this to help your patients:

A patient with GAF scores that are routinely 50 or lower will have a strong claim for Social Security. Likewise, a patient who is unable to work full-time due to mental limitations will have difficulty if his medical records do not contain GAF scores. It is also possible to help a patient by providing an explanation of a GAF score that is over 50. For example: "Mr. Madison has a GAF of 55, because he continues to live in a supportive environment," or "Mr. Madison has a GAF of 55, but work would cause a decline."

This page was last edited July 24, 2006.

Copyright © 2002-2006 Gateway Legal Services, Inc. All rights reserved.