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NeuroSpine doctor can’t document accurately?

Dr. Catherine Gallo performed a physical examination during a consult on a patient in December of 2018. This patient has had numerous abdominal surgeries that have left quite an obvious lengthy midline scar. She claims in her dictated report that she examined multiple body sites and describes her abdominal exam as such: “soft, non-tender, non-distended, no surgical scars, normal bowel sounds all 4 quadrants, no masses noted on light or deep palpation.”

According to the documentation, she would have had to spent a fair amount of time listening and touching and “looking” to perform this examination.

How is it that she could miss such a scar? Probably because she never did the examination that she claims to have done! Fraud? In my opinion, highly likely! Too many physicians use “cut and paste” and other pre-formatted options too easily available within the electronic medical records to document MORE than they actually do, all for the sake of billing the insurance company MORE MONEY!

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