MEDICOLEGAL SERVICES: BILLING AND GENERAL CONSIDERATIONS
Imaging is vital to my assessment of most cases, and I can access
most studies on-line. For almost any study in Rhode Island, and
many in Massachusetts, I can obtain them myself at no additional
charge with authorization to do so. Images will be analyzed, selected,
and inserted into the reports as appropriate. Imaging CDs sent with
records will be returned if requested. We no longer accept imaging
can currently access imaging from the following networks. Given
HIPAA constraints, I will need permission (via e-mail is fine) from
either you, the claimant, or the claimant's attorney.
Radiology (Rhode Island)
(Fatima and RWMC)
MRI of New England
Island Medical Imaging
Deaconess Hospital (hopefully in near future)
RECORD REVIEW RATE: $2.60 per page. $1,500 is the minimum charge
for all new assignments.
Times: I strive for a turnaround time within 10 business days of
receipt of documents or IME. If you have deadlines such as an arbitration
or statute of limitations, please let us know and we are typically
able to accommodate you at an increased rate of 20% for 72 hour
$1,000 per hour with a minimum charge of 2 hours. We have intermittent
access to a suitable conference room for depositions. For off-site
depositions an additional charge for travel at the same hourly rate
MEDICAL EXAMINATION (IME): Please note that we do IMEs both
in MA and RI. These are charged at a flat rate of $2,000 for an
IME. The $2,000 fee includes review of up to 250 pages of medical
records, all correspondence, transcription fees, report preparation,
teleconference, and whole person calculation according to AMA guidelines.
Medical records beyond 250 pages are charged at an additional $2.60/page.
APPEARANCES: My charge for a driving distance court or
arbitration appearance is $10,000. I block off an entire day for
these, and am available (and recommend) a meeting early in the morning
of the trial (gratis). In the event of the need for airplane travel
$5,000 travel time/half day will be billed in addition. We will
not assign time for court appearances until full payment has been
received. My preference is to appear at trial instead of undergoing
an audiovisual deposition. I have arranged my schedule such that
I am available on most Mondays, Tuesdays and Fridays.
RATE: $1000/hour. Hourly rate does not apply to initial Medical
Record Review which is at the flat, per page rate above. This applies
to miscellanea such as additional imaging or medical record review
after initial submission.
OF DOCUMENTS: I am often not informed when cases are dismissed
or settled. If I have not received correspondence regarding a case
for 4 years after the time I have submitted my report, I will destroy
SITE ASSESSMENTS: Please note that the above fees are for evaluation
of EITHER the neck/back OR head. If both a spinal and head (see
below) evaluation are required, due to the increased work that this
involves, a 20% increased fee will be applied. Head includes
closed head injuries, minimal traumatic brain injuries (mTBI), concussions,
and post-concussion syndrome.
MEDIA FOR MEDICAL RECORDS: I strongly request that the information
be sent to me in digital format. This can be a thumb drive, CD,
link to a repository (e.g. Dropbox), or PDF attachment. Approximately
80% of my referrals at this point arrive in that manner. In the
case of paper documents, we will scan them into digital format,
and charge 10 cents per page for doing so. We will then destroy
the paper documents unless you would like us to send them back to
have been experiencing a large number of last minute cancellations
and postponements. Many claimants do not show with no forewarning.
While we understand the difficulties involved with your scheduling
these, and appreciate your involving us in them, we book these months
in advance. We move operations and clinics to accommodate them.
or postponement of IMEs, depositions, and court appearances with
more than 7 business days' notice: A full refund will be
Cancellation or postponement or no show of all scheduled
legal appointments with less than 7 business days' notice:
No refund will be returned.
KEEPING: There has been a remarkable amount of change in the
transmission and maintenance of medical records over the past
several years. We now receive imaging studies and other records
by paper, CD, flash drive, or link to repository, e.g. DropBox.
Our current policy is to maintain paper documents for 4 years.
For example, any case we receive in 2018 will be destroyed in
January of 2022. Imaging studies and surveillance video sent to
us on CD, DVD, or flash drive, or film will be analyzed, and pertinent
images pasted into the medical report. They will then be destroyed
unless we are asked to return them.
OF NOTIFICATION: We check our email several times per day.
In addition to the option of calling our office (401 453-3545),
please send email notice to the below addresses with a return
FOR SERVICES - We are spending increasing amounts of effort
and time collecting fees for our services. If we have not received
payment 2 months (60 days) after you receive our report and invoice,
we will add a surcharge of 1.5% per month.
appreciate your understanding and cooperation. A copy of this policy
will be faxed or emailed to your office at the time of scheduling.
Sample record review performed by Dr. Saris below -
MEDICAL EVALUATION ON MICHAEL SMITH
CHIEF COMPLAINT: Michael is a 61-year-old
man referred for medical evaluation.
HISTORY: This middle-aged man was well until
over four years ago when he claims he was injured seriously at
work. A roughly 600-pound piece of equipment began to fall, and
in attempting to stop it from doing so, he developed acute low
back pain. This was treated by Dr. Jones. Although much improved
compared to before the surgery, he continues to have pain and
other problems at this time.
Prior to this accident, he had never undergone lumbar
imaging. He had never been to a healthcare provider for back problems.
The pain began to hurt immediately, and has gotten better over
time (with the surgery of Dr. Jones). The pain is primarily axial
in the back, though it travels down both hips and then diffusely
into the thighs, legs, and feet. The majority of the pain is axial
and to the right side of the midline. The pain is constant, and
is both moderate-to-severe. He has no comfortable position. It
hurts both at rest and with activity, but is worse with activity.
He has undergone physical therapy that was somewhat
helpful. He has not been to a chiropractor. He has undergone no
spinal injections. He currently takes both tramadol and oxycodone
He was out of work for about two years, but has
currently returned. He is not capable of physically demanding
activity due to his back discomfort. He is independent at home
and can drive a car, though he fails for longer distances.
I asked him about his hip pain, and he says that
the right hurts more than his left. He was very clear that the
hip pain did not start until two years after the 2013 accident
(sometime in 2015). This pain hurts at all times, and he has no
He is currently back working in a carpentry setting.
He no longer does the heavy physical labor, but does supervisory
He takes less than one narcotic tablet per day,
and estimates 2 hydrocodone or 2 oxycodone tablets a week. He
takes daily tramadol.
PERSONAL HISTORY: He is married, and has
FAMILY HISTORY: His parents are both deceased.
DRUG ALLERGIES: None.
HABITS: He neither drinks nor smokes.
CURRENT MEDICATIONS: Tramadol and oxycodone.
REVIEW OF SYSTEMS: Poor exercise tolerance,
painful joints, neck pain, back pain, poor muscle strength, arm
weakness, leg weakness. The patient denied high blood pressure,
arthritis, abdominal pain, abdominal swelling, black, tarry bowel
movements; change in bowel habits, constipation, cirrhosis of
the liver, cramps, diarrhea, gallstones, heartburn, hemorrhoids,
hepatitis, indigestion, nausea, passing of blood from rectum,
stomach or duodenal ulcer, vomiting, vomiting of blood. EARS:
The patient denied drainage from ear, ear pain, or sinus trouble.
GENITOURINARY: The patient denied blood in urine, difficulty
controlling urine, difficulty passing urine, kidney stones, pain
or burning while urinating. NEUROLOGICAL: The patient denied
blurred vision, buzzing, or ringing in ears, difficulty with balance,
difficulty with hearing or deafness, difficulty swallowing, dizzy
spells, double vision, fainting spells, light flashes, memory
loss, persistent hoarseness, severe headaches, speech difficulty,
or stiffness. SKIN: The patient denied changing or bleeding
moles, or rash. NECK: The patient denied neck stiffness,
or new unexplained lumps. BONES & JOINTS: The patient
denied polio, rheumatic fever, or swollen joints. CHEST, HEART,
LUNGS: The patient denied abnormal chest x-ray, abnormal electrocardiogram,
chest pain, enlarged heart, angina, coughing up blood, fluttering
of the heart, frequent cough, heart attack, heart murmur as an
adult, shortness of breath, unusual heartbeat, varicose veins,
wheezing. ENDOCRINE: The patient denied coldness most of
the time, diabetes, goiter, gout, night sweats, overactive thyroid,
poor exercise tolerance, thirstiness, underactive thyroid, unusual
fatigue or sluggishness, unusual jumpiness or nervousness, or
warmness most of the time. PSYCHOLOGICAL PROBLEMS: The
patient denied serious depression and made no mention of any serious
psychiatric disorder. HEMATOLOGIC: The patient denied easy
bruising, nosebleeds not due to injuries, poor blood clotting,
swollen glands, unexplained fevers, chills.
PRIOR SURGICAL HISTORY: Back surgery in August
He is an unusually pleasant and likeable man, who comes in by
himself. Vital signs and measurements were: Height 6 feet 0 inches,
weight 205 pounds, heart rate 80, respirations 16, blood pressure
GENERAL MEDICAL ASSESSMENT:
Carotid artery examination revealed no evidence of bruit or other
abnormality. Heart rhythm was normal without extra sounds or murmurs.
There was no abnormality of the peripheral vascular system and
the right radial pulse was strong. Breath sounds were clear without
rales, rhonchi, or wheezes. The abdomen was soft and non-tender.
No masses were palpated.
Mental status exam was normal. Orientation was normal, and memory
was intact. Attention span and concentration were normal. Receptive
and expressive speech was normal. Fund of knowledge was normal.
Cranial nerve II:
To confrontational testing, there was no peripheral field abnormality.
Visual acuity was intact to reading small print.
Cranial nerve III, IV, VI:
Extraocular movements are full without nystagmus.
Cranial nerve V:
Facial sensation is symmetric.
Cranial nerve VII:
Facial movement is symmetric.
Cranial nerve VIII: Hearing
Cranial nerve IX, X: Palate
elevates in the midline.
Cranial nerve XI: Shoulder
shrug is strong bilaterally.
Cranial nerve XII:
Tongue is midline.
Motor exam of the limbs was intact. There was full
power and tone, and no fasciculations or abnormal movements were
UPPER LIMBS: Deltoid
power (C5) was 5/5 bilaterally, brachioradialis power (C5, 6)
was 5/5 bilaterally, biceps power (C6) was 5/5 bilaterally, triceps
power (C7) was 5/5 bilaterally, long finger flexors (C8) were
5/5 bilaterally, and hand intrinsics (C8, T1) power were 5/5 bilaterally.
Quadriceps power (L4) was 5/5 bilaterally, anterior tibialis (L4,
5) and extensor hallucis power (L5) were 5/5 bilaterally, and
plantar flexion (S1) was normal bilaterally.
1 He gave me written and verbal
permission to review any medical records that are obtainable online.
Sensory examination with a pinwheel was unremarkable
with no focal deficit in a peripheral nerve or root distribution.
Reflexes were normal and symmetric in the upper and lower limbs.
Examination of the neck was normal. When viewed from the side,
the lordotic curve was normal. Range of motion was full. I carefully
palpated and examined the lumbar musculature that consisted of
the latissimi, quadratus lumborum, and multifidus muscles. There
was no atrophy or fasciculation. There was no abnormality of muscle
tension, and no spasm.
He had three of the five Waddell's signs for the
lumbar spine, namely, positive torso rotation test, positive press
test, and excessive pain on examination of his lumbar spine.
Examination of his back showed parallel and linear
PAIN DISABILITY QUESTIONNAIRE: 110.
OSWESTRY DISABILITY QUESTIONNAIRE: 35.
PATIENT NARRATIVE: Before leaving the office,
a clipboard and a piece of paper were given with "Please
write down everything you feel we should know about your accident
and injuries from it." I carefully reviewed what was written,
and it did not add anything to either the record review or the
narrative I took from the patient.
His only comment was why the numbness in his thighs
was not checked.2
TIME IN OFFICE: Arrival at our office was
at 1:37pm. He was seen immediately by our medical assistant, and
then me, and left at 3:09 pm.
2 I checked those with a pinwheel.
| On August 17, 2013, Mr. Smith
claims he was injured seriously (subject accident).
On August 18, 2013, he underwent lumbosacral
x-rays that showed a comminuted compression fracture of L4 with
approximately 25% of loss of height and anterior displacement
of an inferior fragment.
On August 18, 2013, he had pain that was acute.
It was located in the lower back. It began about six days previously
and became worse yesterday after lifting a coke machine. The pain
radiated to the right upper thigh and the left upper thigh. "The
problem was sustained six days ago when going upstairs he slipped
and fell backwards landing on his back on a landing five steps
back." He was seen at Urgent Care Clinic where he complained
of rib pain. The prior day he had lifted a coke machine and had
the acute onset of more pain in his low back. Neurological review
of systems was negative for numbness, tingling, and weakness.
Detailed neurological examination was normal.
His x-rays showed a compression fracture
at L4. An MRI showed foraminal narrowing and abnormal signal in
the soft tissues. The
case was discussed with Dr. Jones.
On August 18, 2013, he underwent lumbosacral
MRI at FH. There was mild central stenosis at L4-L5. There was
compression fracture of L4 which had lost 25% of its height.
On August 18, 2013, he
underwent LS x-rays at FH. There was a compression fracture at
L4. Additional imaging with MR and CT was recommended.
On August 20, 2013, he
underwent lumbosacral x-rays at FH. It was compared to an August
18, 2013, study which was of superior quality.
On August 18, 2013, he
underwent an LS CT at FH. It showed a burst-type fracture of L4
with approximately 25% loss of height. There was mild stenosis
at that level. There were fractures of the 10th and 11th ribs.
On August 18, 2013, he was seen. He is a 56-year-old
man who had fallen six days previously on a flight of stairs landing
on his back. He initially only had low back pain, but the prior
day he was lifting a Coca-Cola machine at work and developed acute
worsening of his low back pain. He was married with two children.
He denied tobacco use and worked as a construction superintendent.
Neurological examination was normal. Neurosurgery
recommended admission for pain control and possible brae fitting.
On August 18, 2013, he
underwent LS CT at FH that showed a L4 fracture.
On August 18, 2013, Dr. Coleman
saw him in the FH ER. He was helping a coworker move a heavy piece
of equipment when he had sudden onset of low back pain. He had
no symptoms or paresthesias. There was no weakness in his legs.
LS MR showed a L4 compression fracture with 25% loss of vertebral
body height. Neurological examination was normal. He will be placed
at bed rest and fitted with an orthotic device.
On August 27, 2013, he underwent a LS CT. There was a slight settling
of L4 from 18 to 16 mm.
On August 27, 2013, Dr. Arns
of the Neurosurgical Service did an initial consultation. He had
been admitted on August 18, 2013, for an L4 burst fracture that
was managed non-operatively with lumbosacral orthosis. He came
in to the emergency room with worsened pain. He believed it occurred
while moving a heavy object on August 17, 2013, and was unrelated
to a fall days previously. He was on OxyContin for pain with increased
leg weakness and numbness. He used a walker and complained of
bilateral foot numbness. He denied saddle anesthesia or sphincter
disturbance. Neurological examination was normal.
He might be a candidate for operative intervention.
On August 28, 2013, Dr.
Jones dictated an operative note. He describes him as a 56-year-old
man, who had a burst fracture after a fall. This was managed conservatively
initially with an orthotic brace. His pain significantly worsened
in spite of narcotics. A follow-up scan showed diminished vertebral
height. He had failed conservative measures, and neurosurgery
On August 28, 2013, a CT
shows interval L3 to L5 fusion with satisfactory hardware alignment.
There was a 6-mm retropulsion with moderate stenosis.
On August 28, 2013, he underwent
an evaluation during a neurosurgical consult by Dr. Risk, a Neurosurgery
Resident. Neurological examination was normal.
On August 31, 2013, a pathology
report from the bone showed no evidence of malignancy.
On September 9, 2013, Dr. Sam dictated a discharge
history and physical. He had undergone an L3 to L5 PPS. He was
discharged on several medications including oxycodone.
On October 2, 2013, a final physical therapy note
describes his attending three visits. His diagnosis was a closed
fracture without a spinal cord injury. He had undergone percutaneous
pedicle screw placement.
On October 10, 2013, Dr. Jones saw him. His medical
course is described in detail. A biopsy was taken and there was
no evidence of tumor. The procedure had been done for internal
stabilization of his spine that had been weakened by the burst
fracture. In a year or two, the instrumentation might be removed.
"At this time, the patient can go back to work." He
could transition to full duty and do not need a brace.
On November 22, 2013, he
underwent a lumbosacral CT scan at FH. It showed an L3 to L5 fusion
with intact hardware and satisfactory alignment. There was some
slight loss of the L4 vertebral height.
On January 6, 2014, Dr. Jones
saw him. He was four months out from L3 to L5 PPS. The pain was
narcotic dependent and he took oxycodone. Neurological
examination was normal. Ongoing conservative measures were
On March 12, 2014, Dr. Jones saw him. He was six
months out from an L3 to L5 percutaneous pedicle screw stabilization
(PPS). He was in physical therapy. He took Tylenol with Codeine.
Neurological examination was normal. He was doing
well and would continue with conservative measures.
On April 2, 2014, Dr. Jones saw him. He had undergone
a L3 to L5 percutaneous pedicle screw stabilization for an L4
burst fracture. He had been undergoing physical therapy.
On May 24, 2014, Dr. Jones saw him. He had seen
him many times since his L4 burst fracture and treated with L3
to L5 percutaneous pedicle screws. He was doing fairly well after
surgery. He had pain and numbness in both of his feet and requested
a disability letter and return to work. His date of birth was
October 26, 1956. Dr. Jones stated, "at this point, I do
not think I can do that. From the spine fracture and the surgery
perspective, I think he has recovered and there should not be
any strict limitations. The limitations maybe no strenuous activity,
no heavy lifting for the back because subjectively the patient
stated he has experiencing pain after physical therapy or any
strenuous physical activity." He stated that from the surgical
perspective, he was doing well and there was no "strong limitation."
He then states "the patient feels his overall body pain and
back pain is from his age and arthritis." He will be seen
on an as needed basis.
On August 15, 2014, he was seen in clinic. There
was a question of a mild peripheral neuropathy. Repeat nerve studies
were recommended. Dr. Mann performed electrodiagnostic studies.
On August 19, 2014, Dr. Pont saw him. He had undergone
surgery for his L4 fracture. EDS showed
normal motor function. He had reduced pin sensation
in his legs. Conservative measures were recommended.
1, 2015, he had gone back to work on a full-time basis. He had
increased pain and limited endurance due to back discomfort. 15
tablets of Percocet per month would be allowed. Conservative measures
On April 3, 2016, he had chronic low back pain and
had not been seen for several months. "He has been doing
fairly well with his full work schedule." He had variation
of pain throughout the day and used either tramadol or oxycodone
on an as needed basis. The pain went across the back and to both
the hips. He took one to two oxycodone tablets per week, and one
to two tramadol tablets per day. Neurological examination
was normal with intact sensation. The impression was chronic
musculoskeletal pain. Conservative measures were recommended.
On August 4, 2017, a physiatrist, wrote a letter
in regard to Mr. Smith. The patient complained of daily, but variable
low back pain in association with bilateral leg, thigh, and hip
pain. The right leg was worse than the left. A medical history
is detailed including the accident and his subsequent treatment.
He describes a March 2017 lumbosacral MRI that showed degenerative
changes from L1 to L4. There was progression of degenerative change
at L3-L4 with bilateral narrowing. He further describes a clinic
visit on August 1, 2017, when he claimed that his right hip pain
was getting worse. He had tenderness to palpation of the right
hip adductors. He was married and working full time as a supervisor
for a construction company. His exercise was limited. Neurological
examination showed no focal weakness, though he had subjective
numbness and tingling in his feet. His diagnoses were a prior
fusion and degenerative lumbar changes. He additionally rendered
the diagnosis of chronic hip and buttock musculoskeletal pain.
He related all of these to the subject accident. He was not at
a medical end result. There was evidence of progression of degenerative
changes at L3-L4 and L5-S1. He might require narcotics to sustain
his level of activity. He applied a 23% whole person impairment
according to the fifth version of the American Medical Association
Guidelines.3 His prognosis was
indefinite and had chronic daily pain.
3 I checked those with a pinwheel.
I reviewed the below imaging studies personally.
On August 18, 2013, he underwent a lumbosacral x-rays.
It shows a compression fracture at L4. The alignment is normal.
On August 18, 2013, he underwent a lumbosacral MRI.
The compression fracture seemed at L4 with normal alignment and
increased signal on the STIR sequence. Spinal canal was widely
On August 18, 2013, he underwent a lumbosacral CT
scan in Boston. It shows the compression fracture at L4 with mild
posterior retropulsion. The spinal canal was widely patent. Coronal
views show no clinically significant translation.
On August 28, 2013, he underwent a pedicle screw
fixation from L3 to L5. Instrumentation is in perfect position.
Alignment is normal.
On November 22, 2013, he underwent a lumbosacral
CT scan. It shows the instrumentation in excellent position. There
has been no further progression of the compression fracture at
L4. Alignment is normal.
In March 2017, he underwent a lumbosacral MRI. It
shows a prior L2-4 fusion. Screws are in satisfactory position.
Is no evidence of any left-sided canal or nerve compromise.
On August 18, 2013, he underwent a lumbosacral x-ray.
It shows a moderate L4 compression fracture. Alignment is normal.
There is approximately a one-quarter loss of height.
ASSESSMENT: I have made the below statements
to a reasonable degree of medical certainty.
Mr. Smith is a middle-aged man who was injured seriously
years ago. He suffered an L4 compression fracture that was treated
successfully by Dr. Jones. I have been asked to comment on any
injuries he has suffered, and his current medical condition as
In this area of medicine, the means by which patients
are evaluated are the neurological examination, neuroimaging,
and electrodiagnostic studies when available. These indicate an
excellent recovery form his structural spine injury. These will
be discussed in detail below.
The neurological examination is an important
part of this assessment. He has undergone examinations by two
neurosurgeons, and more recently a physiatrist. All were normal,
and showed no evidence of nerve damage.
Electrodiagnostic studies are also helpful
adjuncts in these assessments. Dr. Pont performed such an assessment
in August 2014, and it showed no evidence of motor damage.
Neuroimaging is the most important part of
these evaluations. The compression fracture had worsened, and
he underwent an L3-L5 fusion by Dr. Jones on August 28, 2013.
He made an excellent recovery. On October 10, 2013, Dr. Jones
recommended that the patient return to work. He could transition
to full duty and would not need a brace.4
Mr. Smith has made an excellent recovery from his
injury. As it occurred after an incident at work, causation is
established. It has been capably treated by Dr. Jones. Other records
indicate that he has returned to work and is functioning at a
"full work schedule." He requires daily medication and
rare opioids. According to the sixth version of the American Medical
Association Guidelines, he has a whole person impairment of 4%
(see below). He has minimal functional impairment and minimal
disability. He could return to work activity at the USDOL medium
If other records become available such as healthcare
provider notes, imaging studies, deposition testimony, or video
surveillance, these should be obtained and sent to me for review.
If he has seen Dr. Jones subsequent to May 21, 2014, those notes
should be obtained and sent to me for further review.
Signed under the pains and penalties of perjury,
this 31st day of October, 2017.
Lecturer in Neurosurgery
Harvard Medical School
Brigham & Women's Hospital
4 On May 24,
2014, Dr. Jones stated "from the spine fracture and the surgery
perspective, I think he has recovered and there should not be
any strict limitations. The limitations maybe no strenuous activity,
no heavy lifting
On April 3, 2016, Dr. Montview, a physiatrist, saw him. He had
chronic low back pain and had not been seen for several months.
"He has been doing fairly well with his full work schedule."
He took two oxycodone tablets per week and two tramadol tablets
5 UNITED STATES DEPARTMENT OF LABOR, DICTIONARY
OF OCCUPATIONAL TITLES, AND JOB CLASSIFICATIONS
MEDIUM WORK: Employee may exert 20 to 50 pounds of force
occasionally (< 1/3rd of the time) and/or 10 to 25 pounds of
force frequently (1/3rd or 2/3rds of the time) and/or greater
than negligible up to 10 pounds of force constantly (> 2/3rds
of the time) to move objects. Physical demand requirements are
in excess to those for light work.
1. (GMFH-CDX) = NA7
2. (GMPE-CDX) = 0
3. (GMCS-CDX) = 0
Net adjustment (sum of above three)= - 2
MODIFIER= 0 =
Grade modifier A
FINAL WHOLE PERSON IMPAIRMENT=
or inconsistent symptoms
symptoms with strenuous/vigorous activity
symptom with normal activity
symptoms with less than normal activity
symptoms at rest, limited to sedentary activity
to the Evaluation of Permanent Impairment,
2008 American Medical Association, Library of Congress
7 "This is 2 or more points higher
than the class assignment and therefore discounted." page
584, 6th version AMA Guidelines
8 Subjective complaints without objective
physical findings or significant clinical abnormalities are generally
assigned class 0 and have no ratable impairment. Page 561 and
575, 6th version AMA guidelines