34474 Federal Register / Vol. 61, No. 128 / Tuesday, July 2, 1996 / Notices

Medical Source Statement vs. RFC

Assessment

A medical source’s statement about

what an individual can still do is

medical opinion evidence that an

adjudicator must consider together with

all of the other relevant evidence

(including other medical source

statements that may be in the case

record) when assessing an individual’s

RFC. Although an adjudicator may

decide to adopt all of the opinions

expressed in a medical source

statement, a medical source statement

must not be equated with the

administrative finding known as the

RFC assessment. Adjudicators must

weigh medical source statements under

the rules set out in 20 CFR 404.1527 and

416.927, providing appropriate

explanations for accepting or rejecting

such opinions.

From time-to-time, medical sources

may provide opinions that an individual

is limited to ‘‘sedentary work,’’

‘‘sedentary activity,’’ ‘‘light work,’’ or

similar statements that appear to use the

terms set out in our regulations and

Rulings to describe exertional levels of

maximum sustained work capability.

Adjudicators must not assume that a

medical source using terms such as

‘‘sedentary’’ and ‘‘light’’ is aware of our

definitions of these terms. The judgment

regarding the extent to which an

individual is able to perform exertional

ranges of work goes beyond medical

judgment regarding what an individual

can still do and is a finding that may be

dispositive of the issue of disability.

At steps 4 and 5 of the sequential

evaluation process in 20 CFR 404.1520

and 416.920, the adjudicator’s

assessment of an individual’s RFC may

be the most critical finding contributing

to the final determination or decision

about disability. Although the overall

RFC assessment is an administrative

finding on an issue reserved to the

Commissioner, the adjudicator must

nevertheless adopt in that assessment

any treating source medical opinion

(i.e., opinion on the nature and severity

of the individual’s impairment(s)) to

which the adjudicator has given

controlling weight under the rules in 20

CFR 404.1527(d)(2) and 416.927(d)(2).

Opinions on Whether an Individual Is

Disabled

Medical sources often offer opinions

about whether an individual who has

applied for title II or title XVI disability

benefits is ‘‘disabled’’ or ‘‘unable to

work,’’ or make similar statements of

opinions. In addition, they sometimes

offer opinions in other work-related

terms; for example, about an

individual’s ability to do past relevant

work or any other type of work. Because

these are administrative findings that

may determine whether an individual is

disabled, they are reserved to the

Commissioner. Such opinions on these

issues must not be disregarded.

However, even when offered by a

treating source, they can never be

entitled to controlling weight or given

special significance.

Findings of State Agency Medical and

Psychological Consultants

Medical and psychological

consultants in the State agencies are

adjudicators at the initial and

reconsideration determination levels

(except in disability hearings—see 20

CFR 404.914 ff. and 416.1414 ff.). As

such, they do not express opinions; they

make findings of fact that become part

of the determination. However, 20 CFR

404.1527(f) and 416.927(f) provide that,

at the administrative law judge and

Appeals Council levels of the

administrative review process, medical

and psychological consultant findings

about the nature and severity of an

individual’s impairment(s), including

any RFC assessments, become opinion

evidence. Adjudicators at these levels,

including administrative law judges and

the Appeals Council, must consider

these opinions as expert opinion

evidence of nonexamining physicians

and psychologists and must address the

opinions in their decisions. In addition,

under 20 CFR 404.1526 and 416.926,

adjudicators at the administrative law

judge and Appeals Council levels must

consider and address State agency

medical or psychological consultant

findings regarding equivalence to a

listed impairment.

At the administrative law judge and

Appeals Council levels, adjudicators

must evaluate opinion evidence from

medical or psychological consultants

using all of the applicable rules in 20

CFR 404.1527 and 416.927 to determine

the weight to be given to the opinion.

For additional detail regarding these

policies and policy interpretations, see

SSR 96–6p, ‘‘Titles II and XVI:

Consideration of Administrative

Findings of Fact by State Agency

Medical and Psychological Consultants

and Other Program Physicians and

Psychologists at the Administrative Law

Judge and Appeals Council Levels of

Administrative Review; Medical

Equivalence.’’

Requirements for Recontacting Treating

Sources

Because treating source evidence

(including opinion evidence) is

important, if the evidence does not

support a treating source’s opinion on

any issue reserved to the Commissioner

and the adjudicator cannot ascertain the

basis of the opinion from the case

record, the adjudicator must make

‘‘every reasonable effort’’ to recontact

the source for clarification of the

reasons for the opinion.

Explanation of the Consideration Given

to a Treating Source’s Opinion

Treating source opinions on issues

reserved to the Commissioner will never

be given controlling weight. However,

the notice of the determination or

decision must explain the consideration

given to the treating source’s opinion(s).

Effective Date: This Ruling is effective

on the date of its publication in the

Federal Register.

Cross-References: SSR 96–6p, ‘‘Titles

II and XVI: Consideration of

Administrative Findings of Fact by State

Agency Medical and Psychological

Consultants and Other Program

Physicians and Psychologists at the

Administrative Law Judge and Appeals

Council Levels of Administrative

Review; Medical Equivalence,’’ SSR 96–

2p, ‘‘Titles II and XVI: Giving

Controlling Weight to Treating Source

Medical Opinions;’’ and Program

Operations Manual System, section DI

24515.010.

[FR Doc. 96–16688 Filed 7–1–96; 8:45 am]

BILLING CODE 4190–29–P

Social Security Ruling (SSR) 96–8p.

Titles II and XVI: Assessing Residual

Functional Capacity in Initial Claims

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling.

SUMMARY: In accordance with 20 CFR

422.406(b)(1), the Commissioner of

Social Security gives notice of Social

Security Ruling SSR 96–8p. This Ruling

states the Social Security

Administration’s policies and policy

interpretations regarding the assessment

of residual functional capacity (an

individual’s ability to perform sustained

work activities in an ordinary work

setting on a regular and continuing

basis) in initial claims for disability

benefits under title II of the Social

Security Act (the Act) and supplemental

security income payments based on

disability under title XVI of the Act.

EFFECTIVE DATE: July 2, 1996.

FOR FURTHER INFORMATION CONTACT:

Joanne K. Castello, Division of

Regulations and Rulings, Social Security

Administration, 6401 Security

Boulevard, Baltimore, MD 21235, (410)

965–1711.
Federal Register / Vol. 61, No. 128 / Tuesday, July 2, 1996 / Notices 34475

1 However, a finding of ‘‘disabled’’ will be made

for an individual who: a) has a severe

impairment(s), b) has no past relevant work, c) is

age 55 or older, and d) has no more than a limited

education. (See SSR 82–63, ‘‘Titles II and XVI:

Medical-Vocational Profiles Showing an Inability to

Make an Adjustment to Other Work’’ (C.E. 1981–

1985, p. 447.) In such a case, it is not necessary to

assess the individual’s RFC to determine if he or

she meets this special profile and is, therefore,

disabled.

2 The ability to work 8 hours a day for 5 days

a week is not always required when evaluating an

individual’s ability to do past relevant work at step

4 of the sequential evaluation process. Part-time

Continued

SUPPLEMENTARY INFORMATION: Although

we are not required to do so pursuant

to 5 U.S.C. 552 (a)(1) and (a)(2), we are

publishing this Social Security Ruling

in accordance with 20 CFR

422.406(b)(1).

Social Security Rulings make

available to the public precedential

decisions relating to the Federal old-age,

survivors, disability, supplemental

security income, and black lung benefits

programs. Social Security Rulings may

be based on case decisions made at all

administrative levels of adjudication,

Federal court decisions, Commissioner’s

decisions, opinions of the Office of the

General Counsel, and other policy

interpretations of the law and

regulations.

Although Social Security Rulings do

not have the force and effect of the law

or regulations, they are binding on all

components of the Social Security

Administration, in accordance with 20

CFR 422.406(b)(1), and are to be relied

upon as precedents in adjudicating

cases.

If this Social Security Ruling is later

superseded, modified, or rescinded, we

will publish a notice in the Federal

Register to that effect.

(Catalog of Federal Domestic Assistance,

Programs 96.001 Social Security—Disability

Insurance; 96.002 Social Security—

Retirement Insurance; 96.004 Social

Security—Survivors Insurance; 96.005

Special Benefits for Disabled Coal Miners;

96.006 Supplemental Security Income.)

Dated: June 7, 1996.

Shirley S. Chater,

Commissioner of Social Security.

Policy Interpretation Ruling—Titles II

and XVI: Assessing Residual Functional

Capacity in Initial Claims

Purpose: To state the Social Security

Administration’s policies and policy

interpretations regarding the assessment

of residual functional capacity (RFC) in

initial claims for disability benefits

under titles II and XVI of the Social

Security Act (the Act). In particular, to

emphasize that:

1. Ordinarily, RFC is an assessment of

an individual’s ability to do sustained

work-related physical and mental

activities in a work setting on a regular

and continuing basis. A ‘‘regular and

continuing basis’’ means 8 hours a day,

for 5 days a week, or an equivalent work

schedule.

2. The RFC assessment considers only

functional limitations and restrictions

that result from an individual’s

medically determinable impairment or

combination of impairments, including

the impact of any related symptoms.

Age and body habitus are not factors in

assessing RFC. It is incorrect to find that

an individual has limitations beyond

those caused by his or her medically

determinable impairment(s) and any

related symptoms, due to such factors as

age and natural body build, and the

activities the individual was

accustomed to doing in his or her

previous work.

3. When there is no allegation of a

physical or mental limitation or

restriction of a specific functional

capacity, and no information in the case

record that there is such a limitation or

restriction, the adjudicator must

consider the individual to have no

limitation or restriction with respect to

that functional capacity.

4. The RFC assessment must first

identify the individual’s functional

limitations or restrictions and assess his

or her work-related abilities on a

function-by-function basis, including

the functions in paragraphs (b), (c), and

(d) of 20 CFR 404.1545 and 416.945.

Only after that may RFC be expressed in

terms of the exertional levels of work,

sedentary, light, medium, heavy, and

very heavy.

5. RFC is not the least an individual

can do despite his or her limitations or

restrictions, but the most.

6. Medical impairments and

symptoms, including pain, are not

intrinsically exertional or nonexertional.

It is the functional limitations or

restrictions caused by medical

impairments and their related

symptoms that are categorized as

exertional or nonexertional.

Citations (Authority): Sections 223(d)

and 1614(a) of the Social Security Act,

as amended; Regulations No. 4, subpart

P, sections 404.1513, 404.1520,

404.1520a, 404.1545, 404.1546,

404.1560, 404.1561, 404.1569a, and

appendix 2; and Regulations No. 16,

subpart I, sections 416.913, 416.920,

416.920a, 416.945, 416.946, 416.960,

416.961, and 416.969a.

Introduction: In disability

determinations and decisions made at

steps 4 and 5 of the sequential

evaluation process in 20 CFR 404.1520

and 416.920, in which the individual’s

ability to do past relevant work and

other work must be considered, the

adjudicator must assess RFC. This

Ruling clarifies the term ‘‘RFC’’ and

discusses the elements considered in

the assessment. It describes concepts for

both physical and mental RFC

assessments.

This Ruling applies to the assessment

of RFC in claims for initial entitlement

to disability benefits under titles II and

XVI. Although most rules and

procedures regarding RFC assessment in

deciding whether an individual’s

disability continues are the same, there

are some differences.

Policy Interpretation

General

When an individual is not engaging in

substantial gainful activity and a

determination or decision cannot be

made on the basis of medical factors

alone (i.e., when the impairment is

‘‘severe’’ because it has more than a

minimal effect on the ability to do basic

work activities yet does not meet or

equal in severity the requirements of

any impairment in the Listing of

Impairments), the sequential evaluation

process generally must continue with an

identification of the individual’s

functional limitations and restrictions

and an assessment of his or her

remaining capacities for work-related

activities.1 This assessment of RFC is

used at step 4 of the sequential

evaluation process to determine

whether an individual is able to do past

relevant work, and at step 5 to

determine whether an individual is able

to do other work, considering his or her

age, education, and work experience.

Definition of RFC. RFC is what an

individual can still do despite his or her

limitations. RFC is an administrative

assessment of the extent to which an

individual’s medically determinable

impairment(s), including any related

symptoms, such as pain, may cause

physical or mental limitations or

restrictions that may affect his or her

capacity to do work-related physical

and mental activities. (See SSR 96–4p,

‘‘Titles II and XVI: Symptoms,

Medically Determinable Physical and

Mental Impairments, and Exertional and

Nonexertional Limitations.’’) Ordinarily,

RFC is the individual’s maximum

remaining ability to do sustained work

activities in an ordinary work setting on

a regular and continuing basis, and the

RFC assessment must include a

discussion of the individual’s abilities

on that basis. A ‘‘regular and continuing

basis’’ means 8 hours a day, for 5 days

a week, or an equivalent work

schedule.2 RFC does not represent the
34476 Federal Register / Vol. 61, No. 128 / Tuesday, July 2, 1996 / Notices

work that was substantial gainful activity,

performed within the past 15 years, and lasted long

enough for the person to learn to do it constitutes

past relevant work, and an individual who retains

the RFC to perform such work must be found not

disabled.

3See SSR 83–10, ‘‘Titles II and XVI: Determining

Capability to Do Other Work—The Medical

Vocational Rules of Appendix 2’’ (C.E. 1981–1985,

p. 516). SSR 83–10 states that ‘‘(T)he RFC

determines a work capability that is exertionally

sufficient to allow performance of at least

substantially all of the activities of work at a

particular level (e.g., sedentary, light, or medium),

but is also insufficient to allow substantial

performance of work at greater exertional levels.’’

4 For a detailed discussion of the difference

between the RFC assessment, which is an

administrative finding of fact, and the opinion

evidence called the ‘‘medical source statement’’ or

‘‘MSS,’’ see SSR 96–5p, ‘‘Titles II and XVI: Medical

Source Opinions on Issues Reserved to the

Commissioner.’’

5The definition of disability in the Act requires

that an individual’s inability to work must be due

to a medically determinable physical or mental

impairment(s). The assessment of RFC must

therefore be concerned with the impact of a disease

process or injury on the individual. In determining

a person’s maximum RFC for sustained activity,

factors of age or body habitus must not be allowed

to influence the assessment.

least an individual can do despite his or

her limitations or restrictions, but the

most.3 RFC is assessed by adjudicators

at each level of the administrative

review process based on all of the

relevant evidence in the case record,

including information about the

individual’s symptoms and any

‘‘medical source statements’’—i.e.,

opinions about what the individual can

still do despite his or her

impairment(s)—submitted by an

individual’s treating source or other

acceptable medical sources.4

The RFC Assessment Must be Based

Solely on the Individual’s

Impairment(s). The Act requires that an

individual’s inability to work must

result from the individual’s physical or

mental impairment(s). Therefore, in

assessing RFC, the adjudicator must

consider only limitations and

restrictions attributable to medically

determinable impairments. It is

incorrect to find that an individual has

limitations or restrictions beyond those

caused by his or her medical

impairment(s) including any related

symptoms, such as pain, due to factors

such as age or height, or whether the

individual had ever engaged in certain

activities in his or her past relevant

work (e.g., lifting heavy weights.) Age

and body habitus (i.e., natural body

build, physique, constitution, size, and

weight, insofar as they are unrelated to

the individual’s medically determinable

impairment(s) and related symptoms)

are not factors in assessing RFC in

initial claims.5

Likewise, when there is no allegation

of a physical or mental limitation or

restriction of a specific functional

capacity, and no information in the case

record that there is such a limitation or

restriction, the adjudicator must

consider the individual to have no

limitation or restriction with respect to

that functional capacity.

RFC and Sequential Evaluation

RFC is an issue only at steps 4 and 5

of the sequential evaluation process.

The following are issues regarding the

RFC assessment and its use at each of

these steps.

RFC and exertional levels of work.

The RFC assessment is a function-byfunction assessment based upon all of

the relevant evidence of an individual’s

ability to do work-related activities. At

step 4 of the sequential evaluation

process, the RFC must not be expressed

initially in terms of the exertional

categories of ‘‘sedentary,’’ ‘‘light,’’

‘‘medium,’’ ‘‘heavy,’’ and ‘‘very heavy’’

work because the first consideration at

this step is whether the individual can

do past relevant work as he or she

actually performed it.

RFC may be expressed in terms of an

exertional category, such as light, if it

becomes necessary to assess whether an

individual is able to do his or her past

relevant work as it is generally

performed in the national economy.

However, without the initial functionby-function assessment of the

individual’s physical and mental

capacities, it may not be possible to

determine whether the individual is

able to do past relevant work as it is

generally performed in the national

economy because particular occupations

may not require all of the exertional and

nonexertional demands necessary to do

the full range of work at a given

exertional level.

At step 5 of the sequential evaluation

process, RFC must be expressed in

terms of, or related to, the exertional

categories when the adjudicator

determines whether there is other work

the individual can do. However, in

order for an individual to do a full range

of work at a given exertional level, such

as sedentary, the individual must be

able to perform substantially all of the

exertional and nonexertional functions

required in work at that level. Therefore,

it is necessary to assess the individual’s

capacity to perform each of these

functions in order to decide which

exertional level is appropriate and

whether the individual is capable of

doing the full range of work

contemplated by the exertional level.

Initial failure to consider an

individual’s ability to perform the

specific work-related functions could be

critical to the outcome of a case. For

example:

1. At step 4 of the sequential

evaluation process, it is especially

important to determine whether an

individual who is at least ‘‘closely

approaching advanced age’’ is able to do

past relevant work because failure to

address this issue at step 4 can result in

an erroneous finding that the individual

is disabled at step 5. It is very important

to consider first whether the individual

can still do past relevant work as he or

she actually performed it because

individual jobs within an occupational

category as performed for particular

employers may not entail all of the

requirements of the exertional level

indicated for that category in the

Dictionary of Occupational Titles and

its related volumes.

2. The opposite result may also occur

at step 4 of the sequential evaluation

process. When it is found that an

individual cannot do past relevant work

as he or she actually performed it, the

adjudicator must consider whether the

individual can do the work as it is

generally performed in the national

economy. Again, however, a failure to

first make a function-by-function

assessment of the individual’s

limitations or restrictions could result in

the adjudicator overlooking some of an

individual’s limitations or restrictions.

This could lead to an incorrect use of an

exertional category to find that the

individual is able to do past relevant

work as it is generally performed and an

erroneous finding that the individual is

not disabled.

3. At step 5 of the sequential

evaluation process, the same failures

could result in an improper application

of the rules in appendix 2 to subpart P

of the Regulations No. 4 (the ‘‘MedicalVocational Guidelines) and could make

the difference between a finding of

‘‘disabled’’ and ‘‘not disabled.’’ Without

a careful consideration of an

individual’s functional capacities to

support an RFC assessment based on an

exertional category, the adjudicator may

either overlook limitations or

restrictions that would narrow the

ranges and types of work an individual

may be able to do, or find that the

individual has limitations or restrictions

that he or she does not actually have.

RFC represents the most that an

individual can do despite his or her

limitations or restrictions. At step 5 of

the sequential evaluation process, RFC

must not be expressed in terms of the

lowest exertional level (e.g., ‘‘sedentary’’

or ‘‘light’’ when the individual can

perform ‘‘medium’’ work) at which the

medical-vocational rules would still

direct a finding of ‘‘not disabled.’’ This
Federal Register / Vol. 61, No. 128 / Tuesday, July 2, 1996 / Notices 34477

6 In the Fourth Circuit, adjudicators are required

to adopt a finding, absent new and material

evidence, regarding the individual’s RFC made in

a final decision by an administrative law judge or

the Appeals Council on a prior disability claim

arising under the same title of the Act. In this

jurisdiction, an unfavorable determination or

decision using the lowest exertional level at which

the rules would direct a finding of not disabled

could result in an unwarranted favorable

determination or decision on an individual’s

subsequent application; for example, if the

individual’s age changes to a higher age category

following the final decision on the earlier

application. See Acquiescence Ruling (AR) 94–2(4),

‘‘Lively v. Secretary of Health and Human Services,

820 F.2d 1391 (4th Cir. 1987)—Effect of Prior

Disability Findings on Adjudication of a

Subsequent Disability Claim Arising Under the

Same Title of the Social Security Act—Titles II and

XVI of the Social Security Act.’’ AR 94–2(4) applies

to disability findings in cases involving claimants

who reside in the Fourth Circuit at the time of the

determination or decision on the subsequent claim.

would concede lesser functional

abilities than the individual actually

possesses and would not reflect the

most he or she can do based on the

evidence in the case record, as directed

by the regulations.6

The psychiatric review technique. The

psychiatric review technique described

in 20 CFR 404.1520a and 416.920a and

summarized on the Psychiatric Review

Technique Form (PRTF) requires

adjudicators to assess an individual’s

limitations and restrictions from a

mental impairment(s) in categories

identified in the ‘‘paragraph B’’ and

‘‘paragraph C’’ criteria of the adult

mental disorders listings. The

adjudicator must remember that the

limitations identified in the ‘‘paragraph

B’’ and ‘‘paragraph C’’ criteria are not an

RFC assessment but are used to rate the

severity of mental impairment(s) at

steps 2 and 3 of the sequential

evaluation process. The mental RFC

assessment used at steps 4 and 5 of the

sequential evaluation process requires a

more detailed assessment by itemizing

various functions contained in the broad

categories found in paragraphs B and C

of the adult mental disorders listings in

12.00 of the Listing of Impairments, and

summarized on the PRTF.

Evidence Considered

The RFC assessment must be based on

all of the relevant evidence in the case

record, such as: • Medical history, • Medical signs and laboratory

findings, • The effects of treatment, including

limitations or restrictions imposed by

the mechanics of treatment (e.g.,

frequency of treatment, duration,

disruption to routine, side effects of

medication), • Reports of daily activities, • Lay evidence, • Recorded observations, • Medical source statements,

• Effects of symptoms, including

pain, that are reasonably attributed to a

medically determinable impairment, • Evidence from attempts to work, • Need for a structured living

environment, and • Work evaluations, if available.

The adjudicator must consider all

allegations of physical and mental

limitations or restrictions and make

every reasonable effort to ensure that the

file contains sufficient evidence to

assess RFC. Careful consideration must

be given to any available information

about symptoms because subjective

descriptions may indicate more severe

limitations or restrictions than can be

shown by objective medical evidence

alone.

In assessing RFC, the adjudicator

must consider limitations and

restrictions imposed by all of an

individual’s impairments, even those

that are not ‘‘severe.’’ While a ‘‘not

severe’’ impairment(s) standing alone

may not significantly limit an

individual’s ability to do basic work

activities, it may—when considered

with limitations or restrictions due to

other impairments—be critical to the

outcome of a claim. For example, in

combination with limitations imposed

by an individual’s other impairments,

the limitations due to such a ‘‘not

severe’’ impairment may prevent an

individual from performing past

relevant work or may narrow the range

of other work that the individual may

still be able to do.

Exertional and Nonexertional

Functions

The RFC assessment must address

both the remaining exertional and

nonexertional capacities of the

individual.

Exertional Capacity

Exertional capacity addresses an

individual’s limitations and restrictions

of physical strength and defines the

individual’s remaining abilities to

perform each of seven strength

demands: Sitting, standing, walking,

lifting, carrying, pushing, and pulling.

Each function must be considered

separately (e.g., ‘‘the individual can

walk for 5 out of 8 hours and stand for

6 out of 8 hours’’), even if the final RFC

assessment will combine activities (e.g.,

‘‘walk/stand, lift/carry, push/pull’’).

Although the regulations describing the

exertional levels of work and the

Dictionary of Occupational Titles and

its related volumes pair some functions,

it is not invariably the case that treating

the activities together will result in the

same decisional outcome as treating

them separately.

It is especially important that

adjudicators consider the capacities

separately when deciding whether an

individual can do past relevant work.

However, separate consideration may

also influence decisionmaking at step 5

of the sequential evaluation process, for

reasons already given in the section on

‘‘RFC and Sequential Evaluation.’’

Nonexertional Capacity

Nonexertional capacity considers all

work-related limitations and restrictions

that do not depend on an individual’s

physical strength; i.e., all physical

limitations and restrictions that are not

reflected in the seven strength demands,

and mental limitations and restrictions.

It assesses an individual’s abilities to

perform physical activities such as

postural (e.g., stooping, climbing),

manipulative (e.g., reaching, handling),

visual (seeing), communicative (hearing,

speaking), and mental (e.g.,

understanding and remembering

instructions and responding

appropriately to supervision). In

addition to these activities, it also

considers the ability to tolerate various

environmental factors (e.g., tolerance of

temperature extremes).

As with exertional capacity,

nonexertional capacity must be

expressed in terms of work-related

functions. For example, in assessing

RFC for an individual with a visual

impairment, the adjudicator must

consider the individual’s residual

capacity to perform such work-related

functions as working with large or small

objects, following instructions, or

avoiding ordinary hazards in the

workplace. In assessing RFC with

impairments affecting hearing or

speech, the adjudicator must explain

how the individual’s limitations would

affect his or her ability to communicate

in the workplace. Work-related mental

activities generally required by

competitive, remunerative work include

the abilities to: understand, carry out,

and remember instructions; use

judgment in making work-related

decisions; respond appropriately to

supervision, co-workers and work

situations; and deal with changes in a

routine work setting.

Consider the Nature of the Activity

Affected

It is the nature of an individual’s

limitations or restrictions that

determines whether the individual will

have only exertional limitations or

restrictions, only nonexertional

limitations or restrictions, or a

combination of exertional and

nonexertional limitations or restrictions.

For example, symptoms, including pain,

are not intrinsically exertional or

nonexertional. Symptoms often affect
34478 Federal Register / Vol. 61, No. 128 / Tuesday, July 2, 1996 / Notices

7See Footnote 2.

8A medical source opinion that an individual is

‘‘disabled’’ or ‘‘unable to work,’’ has an

impairment(s) that meets or is equivalent in severity

to the requirements of a listing, has a particular

RFC, or that concerns the application of vocational

factors, is an opinion on an issue reserved to the

Commissioner. Every such opinion must still be

considered in adjudicating a disability claim;

however, the adjudicator will not give any special

significance to the opinion because of its source.

See SSR 96–5p, ‘‘Titles II and XVI: Medical Source

Opinions on Issues Reserved to the Commissioner.’’

For further information about the evaluation of

medical source opinions, SSR 96–6p, ‘‘Titles II and

XVI: Consideration of Administrative Findings of

Fact by State Agency Medical and Psychological

Consultants and Other Program Physicians and

Psychologists at the Administrative Law Judge and

Appeals Council Levels of Administrative Review;

Medical Equivalence.’’

the capacity to perform one of the seven

strength demands and may or may not

have effects on the demands of

occupations other than the strength

demands. If the only limitations or

restrictions caused by symptoms, such

as pain, are in one or more of the seven

strength demands (e.g., lifting) the

limitations or restrictions will be

exertional. On the other hand, if an

individual’s symptoms cause a

limitation or restriction that affects the

individual’s ability to meet the demands

of occupations other than their strength

demands (e.g., manipulation or

concentration), the limitation or

restriction will be classified as

nonexertional. Symptoms may also

cause both exertional and nonexertional

limitations.

Likewise, even though mental

impairments usually affect

nonexertional functions, they may also

limit exertional capacity by affecting

one or more of the seven strength

demands. For example, a mental

impairment may cause fatigue or

hysterical paralysis.

Narrative Discussion Requirements

The RFC assessment must include a

narrative discussion describing how the

evidence supports each conclusion,

citing specific medical facts (e.g.,

laboratory findings) and nonmedical

evidence (e.g., daily activities,

observations). In assessing RFC, the

adjudicator must discuss the

individual’s ability to perform sustained

work activities in an ordinary work

setting on a regular and continuing basis

(i.e., 8 hours a day, for 5 days a week,

or an equivalent work schedule 7), and

describe the maximum amount of each

work-related activity the individual can

perform based on the evidence available

in the case record. The adjudicator must

also explain how any material

inconsistencies or ambiguities in the

evidence in the case record were

considered and resolved.

Symptoms. In all cases in which

symptoms, such as pain, are alleged, the

RFC assessment must:

• Contain a thorough discussion and

analysis of the objective medical and

other evidence, including the

individual’s complaints of pain and

other symptoms and the adjudicator’s

personal observations, if appropriate;

• Include a resolution of any

inconsistencies in the evidence as a

whole; and

• Set forth a logical explanation of the

effects of the symptoms, including pain,

on the individual’s ability to work.

The RFC assessment must include a

discussion of why reported symptomrelated functional limitations and

restrictions can or cannot reasonably be

accepted as consistent with the medical

and other evidence. In instances in

which the adjudicator has observed the

individual, he or she is not free to

accept or reject that individual’s

complaints solely on the basis of such

personal observations. (For further

information about RFC assessment and

the evaluation of symptoms, see SSR

96–7p, ‘‘Titles II and XVI: Evaluation of

Symptoms in Disability Claims:

Assessing the Credibility of an

Individual’s Statements.’’)

Medical opinions. The RFC

assessment must always consider and

address medical source opinions. If the

RFC assessment conflicts with an

opinion from a medical source, the

adjudicator must explain why the

opinion was not adopted.

Medical opinions from treating

sources about the nature and severity of

an individual’s impairment(s) are

entitled to special significance and may

be entitled to controlling weight. If a

treating source’s medical opinion on an

issue of the nature and severity of an

individual’s impairment(s) is wellsupported by medically acceptable

clinical and laboratory diagnostic

techniques and is not inconsistent with

the other substantial evidence in the

case record, the adjudicator must give it

controlling weight. (See SSR 96–2p,

‘‘Titles II and XVI: Giving Controlling

Weight to Treating Source Medical

Opinions,’’ and SSR 96–5p, ‘‘Titles II

and XVI: Medical Source Opinions on

Issues Reserved to the

Commissioner.’’) 8

Effective Date: This ruling is effective

on the date of its publication in the

Federal Register.

Cross-References: SSR 82–52, ‘‘Titles

II and XVI: Duration of the Impairment’’

(C.E. 1981–1985, p. 328), SSR 82–61,

‘‘Titles II and XVI: Past Relevant Work—

The Particular Job Or the Occupation As

Generally Performed’’ (C.E. 1981–1985,

p. 427), SSR 82–62, ‘‘Titles II and XVI:

A Disability Claimant’s Capacity To Do

Past Relevant Work, In General’’ (C.E.

1981–1985, p. 400), SSR 83–20, ‘‘Titles

II and XVI: Onset of Disability’’ (C.E.

1981–1985, p. 375), SSR 85–16, ‘‘Titles

II and XVI: Residual Functional

Capacity for Mental Impairments’’ (C.E.

1981–1985, p. 390), SSR 86–8, ‘‘Titles II

and XVI: The Sequential Evaluation

Process’’ (C.E. 1986, p. 78), SSR 96–6p,

‘‘Titles II and XVI: Consideration of

Administrative Findings of Fact by State

Agency Medical and Psychological

Consultants and Other Program

Physicians and Psychologists at the

Administrative Law Judge and Appeals

Council Levels of Administrative

Review; Medical Equivalence,’’ SSR 96–

2p, ‘‘Titles II and XVI: Giving

Controlling Weight to Treating Source

Medical Opinions,’’ SSR 96–4p, ‘‘Titles

II and XVI: Symptoms, Medically

Determinable Physical and Mental

Impairments, and Exertional and

Nonexertional Limitations,’’ SSR 96–5p,

‘‘Titles II and XVI: Medical Source

Opinions on Issues Reserved to the

Commissioner,’’ SSR 96–9p, ‘‘Titles II

and XVI: Determining Capability to Do

Other Work—Implications of a Residual

Functional Capacity for Less Than a

Full Range of Sedentary Work,’’ SSR

96–7p, ‘‘Titles II and XVI: Evaluation of

Symptoms in Disability Claims:

Assessing the Credibility of an

Individual’s Statements;’’ and Program

Operations Manual System, sections DI

22515.010, DI 24510.000 ff., DI

24515.002–DI 24515.007, DI 24515.061–

DI 24515.062, DI 24515.064, DI

25501.000 ff., DI 25505.000 ff., and DI

28015.000 ff.

[FR Doc. 96–16691 Filed 7–1–96; 8:45 am]

BILLING CODE 4190–29–P

Social Security Ruling SSR 96–9p.,

Titles II and XVI: Determining

Capability To Do Other Work—

Implications of a Residual Functional

Capacity for Less Than a Full Range of

Sedentary Work

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling.

SUMMARY: In accordance with 20 CFR

422.406(b)(1), the Commissioner of

Social Security gives notice of Social

Security Ruling SSR 96–9p. This Ruling

explains the Social Security

Administration’s policies regarding the

impact of a residual functional capacity

assessment for less than a full range of

sedentary work on an individual’s

ability to do other work.

EFFECTIVE DATE: July 2, 1996.