1. Disability Determination Comprehensive Report (DDCR)
• Payment up to a maximum of $40 for reports generated by the medical provider.
• Payment up to a maximum of $25 for reports generated with the DDS telerecorder system.
• DDS requires timely, comprehensive reports to be submitted in accordance with the medical and psychological examinations. The report fee is available only in conjunction with exams, not in conjunction with psychological testing, speech/language evaluation, ancillary or laboratory testing or studies. The DDCR fee may be paid in addition to the examination fees.
2. DDCR requirements for medical exams
• A comprehensive report is to be provided in a timely manner after the examination, to include:
a. Discussion of pertinent history with source of history and an estimate of the reliability of the history.
b. History of present illness, including reason for not working when appropriate for adults.
c. Factors which increase problems/impairments.
d. Factors which may provide relief.
e. Claimant’s (or child’s) description of how the impairment limits the ability to function.
f. When appropriate for a child’s exam, documentation related to growth and development history, developmental milestones including speech and language, and school performance.
• Information must be in narrative rather than questionnaire or check-off form. Current medication should be listed by name of drug and dose. Social history and family history if pertinent shall be documented. Review of systems should describe other impairments and symptoms the claimant has experienced relative to specific organ systems. Pertinent negative findings, which would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairments, shall be documented. The report should also include:
a. Blood pressure
b. Pulse rate
c. Respiratory rate
d. Height/weight without shoes
e. Head circumference if the child is under age 3
f. Tanner stage as appropriate
g. Description of claimant’s general appearance and pertinent behavior during the examination.
h. Any other pertinent information specific to the specialty of the provider.
3. DDCR requirements for psychological exams
• A comprehensive report is to be provided in a timely manner after the examination, to include:
a. Discussion of pertinent history with source of history and an estimate of the reliability of the history.
b. History of present illness including reason for not working.
c. Factors which increase problems/impairments.
d. Factors which may provide relief.
e. Claimant’s description of how the impairment limits the ability to function.
• Information must be in narrative rather than questionnaire or check-off form. Current medication should be listed by name of drug and dose. Social history and family history if pertinent shall be documented. Pertinent negative findings, which would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairments, shall be documented.