How Residual Functional Capacity affects Social Security Disability and SSI claims

On this site we often mention a concept known as RFC, or residual functional capacity. This basically stands for what a disability claimant can still do, despite the effect of their condition(s) and the limitations imposed by their condition(s).

An RFC is used by a disability examiner to rate a claimant's residual functional capacity. By doing this, a disability examiner can "peg hole" a claimant into a functional category and then go through a process of determining whether or not the claimant can A) return to their past work or, if they can't do their past work, B) perform some type of other work. Claimants who can't return to their past work or do "other work" may be approved for disability.

How does this all work, procedurally? Here's how. The examiner who is assigned to a case will gather the claimant's medical records (this can take weeks or months). Then the examiner will go through the records and discern whether or not the claimant has a listing level impairment (i.e. does the claimant have a condition that is contained in the Social Security Disability list of impairments, and does the claimant's condition satisfy the criteria listed in the book for that particular condition?).

If the claimant has a listing level impairment, they may be approved on the basis of that listing (examples of listings include rheumatoid arthritis, myasthenia gravis, multiple sclerosis, parkinson's disease, etc). If the claimant does not have a listing level impairment, then the examiner will perform sequential evaluation.

What is sequential evaluation? Forget the gobbledygook you get from government websites. Here's what it is. The examiner will rate your RFC based on your medical records. There are variations of RFC ratings, but they basically fall into these categories:

A) Less than sedentary - you are not capable of even doing a sedentary job.

B) Sedentary - you can't do work other than what is considered sedentary, meaning that light, medium, and heavy exertional work is not possible.

C) Light - you can do light work, but can't do more such as medium or heavy work.

D) Medium - You are capable of medium exertion work and can't do anything more than this.

What happens after your RFC assessment has been made? The examiner will look at your work history (the jobs you cited when you applied and whatever information the examiner was able to dig up). Using that work history information and your RFC assessment (which was made using your available medical records), the examiner will determine whether you can do your past work or some form of other work.

The process may seem confusing to those who have never processed disability cases, but here's an example of the process (and please bear in mind this is a very simplified one since the evaluative process can involve other issues).

Let's say your RFC limits you to light work. If your RFC limits you to light work, then, obviously, you can't do medium or heavy work jobs.

Will you get approved for disability? Well, in one scenario, if the work you did in the past was light work, then social security will probably consider you able to return to your past work. Why? Because you've been given an RFC assessment that has rated you with the ability to do light work, which is the same exertional-level work you performed in the past.

If in a different scenario, however, the work you did in the past was medium (the ability to lift 25lbs frequently and 50lbs occasionally), you obviously won't be able to do this because you've been limited to light work. This situation, as examiners say, "gets you out of past work".

Will you then get approved for disability in this scenario? Well, maybe yes, maybe no. It all comes down to the examiner (or the judge depending on what level your claim is at) deciding on whether or not you can do work that falls into a category known as "other work".

Other work...can potentially mean anything. It includes jobs you've never done and jobs that may not even exist in your state. But as long as they exist in the national economy (example - you live in Florida and there are 2000 positions for a certain job in the country but they are all in Iowa), social security may decide to deny your disability based on your ability to do other work.

Whether or not social security will actually deny you on the basis of stating that you can do some form of other work will be based on a number of factors including your age, work skills, education, and your functional limitations, as rated on your residual functional capacity assessment.

At this point in this post you may have realized, it is very important for an applicant to provide a full list of their medical treatment sources and a full listing of their work history. Because both will be needed to properly rate you and determine your eligibility for benefits. It also points out how crucial this thing called RFC, or residual functional capacity really is.

So now to the next part. How does the RFC assessment get made. Basically, the examiner reads your records and then "feels" his or her way toward deciding what your residual functional capacity is (because, remember, disability examiners don't really have medical training, they're only trained to read and interpret records in the context of Social Security Disability guidelines, similar to a disability insurance adjuster).

Once the examiner "comes up with" what he thinks your residual functional capacity is, he visits the doctor who is assigned to his unit. This unit medical consultant will review the examiner's writeup and if he agrees with it (with the RFC that the examiner has given the claimant), the doctor will signoff on the case and, for the most part, the case is done.

Obviously, the social security administration considers it very important that a physician, an M.D., will ultimately decide the residual functional capacity of a disability claimant, instead of just leaving the decision to an examiner who has simply been trained to read medical records and medical terminology (except, of course, for single decision makers). When it comes to deciding whether or not a claimant will be approved or denied for disability, a physician should be involved in determining what the claimant's limitations are, i.e. can they do their past work?, can they do some form of other work, or do they need to be put on disability?

The only problem in all of this: the doctor who works with the disability examiner has never once seen the claimant. He has never treated the claimant. He, in fact, knows nothing more about the claimant than the examiner does from reading the claimant's medical records (though, arguably, being an M.D. he should be able to interpret them better).

Why is this issue important? Because a doctor who has actually provided treatment to a claimant will always know more about that individual (including that individual's limitions and ability or inability to work) than a government-employed doctor who has never once met the claimant.

Obviously, it would make much more sense if the social security administration requested RFC forms from the doctors who treat their patients (these are known as treating physicians).

So, why doesn't the social security administration do this? Very good question. And the answer probably has to do with cost. The cost of printing forms, sending forms out to treating physicians, and the cost, of course, of paying physicians to complete RFC forms for the social security administration (for those who may not be aware, social security pays for the records that are obtained from individual doctor's offices).

However, there is quite possibly another cost: the cost that comes with greater numbers of approved claims which I believe would be the case if the social security administration actually took the time to get detailed statements from the doctors of claimants, versus just getting the medical records which usually say very little about a claimant's functional limitations (very convenient, some would say).

However, just because social security does not send out a residual functional capacity form to its claimants does not mean that a claimant is prevented from doing the same. Disability lawyers, in fact, routinely send out such forms to treating physicians in preparation for a hearing. Why? Because they know that it tends to increase the probability of approval.

Why? Because an RFC form that has been completed by a treating physician will advise a federal administrative law judge as to the functional limitations of a claimant. In other words, it will directly inform the judge as to what the individual is capable of doing and not capable of doing. Can the claimant return to their past work? Can the claimant perform some type of other work? Should the claimant be approved for disability? An RFC form completed by a claimant's treating physician effectively answers these questions for a judge.

Will an RFC form be as effective at the lower levels, i.e. at the initial claim and reconsideration levels? That, unfortunately, may be anyone's guess. The various state agencies that render disability determinations for Social Security Disability and SSI disability claims seem to have a culture of denial that allows them to discount, even ignore, evidence that points to an approval of a claim (I base this statement on my own work experience as a disability examiner, having observed the effects of DDS supervisors on the decision process). Nonethless, submitting an RFC form (completed by a treating physician) at the lower levels may still be a worthwhile component in one's attempt to win disability benefits.

Medical Source statement PDF download

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

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