Should a patient with significant functional limitations, such as difficulty bending, be referred for a functional assessment with a Physical Therapist (PT)?

Functional Assessment Referral for SSDI Documentation

For SSDI functional status documentation, you should complete the functional assessment yourself using standardized questionnaires rather than routinely referring to physical therapy, as PT functional capacity evaluations are designed for return-to-work decisions and rehabilitation planning, not disability determination. 1, 2

Why You Should Document Functional Status Directly

• SSDI requires physician assessment of functional limitations, not PT evaluation, as the primary care provider's opinion on activities like bending, standing, walking, and lifting directly informs disability determination 1
• Functional capacity evaluations by PT are designed for different purposes: they assess maximum physical capacity for return-to-work planning and rehabilitation goal-setting, not for documenting disability 2
• You can efficiently assess functional status using brief validated questionnaires that report activity levels in metabolic equivalents (METs) and evaluate performance, capacity, pain, and activity limitations 3

When PT Referral IS Appropriate

Refer to PT for formal functional capacity evaluation only when:

• The patient's functional limitations are unclear or inconsistent with objective findings, and you need objective measurement of maximum physical capacity 1, 2
• There is potential for rehabilitation to improve function, and you need baseline measurements to track progress 4, 5
• The patient has complex neuromuscular or musculoskeletal impairments requiring specialized assessment of strength, range of motion, balance, and mobility 4

How to Document Functional Status for SSDI

Use standardized assessment approaches:

• Document specific functional limitations in terms of duration and frequency: ability to stand (minutes), walk (distance), sit (hours), lift/carry (weight), bend/stoop (frequency) 4, 3
• Assess both performance (what patient actually does) and capacity (maximum attainable activity level), as these may differ significantly 3
• Evaluate factors contributing to functional decline: pain severity and location, fatigue, acute care utilization, and recent changes in activity level 3
• Quantify activity levels using validated questionnaires that standardize responses to METs, providing objective comparison across patients 3

Common Pitfalls to Avoid

• Don't delay SSDI documentation waiting for PT evaluation when you have sufficient clinical information to assess functional limitations 1
• Don't confuse functional capacity evaluation with functional status assessment: FCE measures maximum capacity under controlled conditions, while SSDI needs real-world functional limitations 2
• Don't rely solely on patient self-report without correlating with objective findings, medication requirements, and clinical course 3
• Recognize that PT functional capacity evaluations typically take 4-8 hours and may not be covered by insurance for disability documentation purposes 2

Specific Documentation Requirements

For bending specifically, document:

• Frequency patient can bend/stoop without significant pain or limitation (never, occasionally, frequently, constantly) 1
• Whether bending limitation is due to pain, weakness, balance impairment, or structural limitation 4
• Impact on activities of daily living and instrumental activities of daily living 3
• Correlation with objective findings (range of motion measurements, imaging, neurological examination) 4