To clarify policy for assessing residual functional capacity (RFC) under title II and XVI and to specify responsibility for the RFC assessment.
Sections 223(d)(2)(A) and 1614(a)(3)(B) of the Social Security Act, as amended, and Regulations No. 4, Subpart P, Section 404.1502(b) and Regulations No. 16, Subpart I, Section 416.902(b). PERTINENT HISTORY: In June 1957, the Commissioner of Social Security recommended for inclusion in the regulations the consideration of nonmedical (vocational) factors in the disability determination process. Initially, Regulations No. 4, Section 404.1501, published that same year, mentioned vocational factors in Section 404.1501(b); with the inception of the Supplemental Security Income Program, these considerations were also reflected in Regulations NO. 16, Section 416.902(b).
Assessment of functional capacity should preferably be reported by a physician who has examined the claimant. When a treatment or examination report is silent with respect to RFC, or the assessment reported is inconsistent with the evidence, the Disability Determination Services (DDS) staff physician generally has provided an assessment on the basis of all the pertinent evidence in file. In some cases, where the medical information is equivocal or for some other reason the RFC is unclear, a work evaluation center has been used to evaluate an individual's capabilities and limitations. However, the policy has not been clear with respect to the responsibility for assessing the RFC in cases where the usual methods prove to be impractical or impossible. As a result, cases have been adjudicated without a complete or well delineated assessment of RFC. Failure to adequately document the file as to RFC enhances the possibility for judgmental errors and may lead to faulty adjudicative conclusions. Moreover, such failure also makes a potentially correct, but incompletely supported, adjudicative conclusion assailable and subject to reversal.
An RFC assessment is necessary for any decision to support the adjudicative conclusion. The RFC assessment may be provided by a treating or examining physician, consultative physician, DDS, Claims Review Section (CRS), or Central Office (CO) staff physicians, work evaluation center, or any other source qualified to make medical judgments. However, the responsibility for providing the RFC assessment that is consistent with the evidence in file rests finally with the DDS staff physician who evaluates the medical evidence in file including the medical opinions of reporting services. A DDS staff physician may endorse an assessment that has been provided by a medical source. He may, on the other hand, provide an RFC assessment based on the evidence in file when no actual assessment has been provided or when, in his medical judgment, the provided assessment made by another source is inconsistent with the total evidence. Suitable rationale for the DDS physician's position in the latter situation should be noted in the file.
In those unusual cases where the degree of specificity necessary to evaluate a particular individual's RFC, cannot be provided by the physicians involved; i.e., examining, treating and DDS staff physicians, the DDS lay adjudicators should evaluate the evidence in file to determine the individual's capacity to perform job-related activities. In such situations, the disability determination should reflect the considerations as to how the RFC and the specific job-related requirements which the claimant is capable of performing are supportive of the adjudicative conclusion in light of the total evidence.
Each disability decision based on Regulations 404.1502(b) or 416(902(b) requires an RFC assessment with respect to those specific physical or mental capacities that are in issue by reason of the individual's allegations or evidence submitted on his behalf. Where an issue does not exist with respect to particularly physical or mental capacities, the presumption is that those capacities are not diminished since the claimant has the burden of proving that he is disabled and of raising any issue with respect thereto, either specifically or by way of medical findings submitted on his behalf.
Hence, the RFC assessment need not make findings with respect to capacities not in issue. RFC assessment may be based solely on medical evidence where such evidence includes sufficient objective findings (e.g., signs, symptoms, and laboratory findings) to permit and support judgments, where relevant, about the individual's capacity for (1) work-related functions, such as standing, lifting, carrying, and handling, (which can be translated into functional capacity for sedentary, light, medium, heavy or very heavy work), (2) mental demands, such as making judgments and tolerating job-related stress, and (3) sensory requirements, such as hearing and seeing. On the other hand, where the medical findings in and of themselves are not fully supportive of an adequate assessment of RFC, such additional factors as the claimant's description of his impairment, recorded observations of the claimant, and any other evidence in file may be considered in conjunction with the medical findings in deriving the RFC.
Residual functional capacity assessments that describe an individual's ability to sustain work-related activities in terms of an ordinary work day on a continuous day-to-day basis can be matched to the physical and mental demands of jobs. Such assessments permit conclusions that an individual can perform substantial gainful work. Conversely, where an RFC assessment establishes that the individual does not have the capacity for work-related functions or establishes that he has the capacity for such functions only on an erratic basis, it permits a finding of inability to perform substantial gainful work.
Disability Insurance State Manual 249.2
Disability Insurance Letter III-3
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