SCENARIO 1
You are a hospitalist admitting a Medicare patient with chest pain. Your index of
suspicion is high that this patient could be having a cardiac event. Based on your clinical judgment,
you initially classify the patient as an inpatient admission. A few minutes later, you are
paged by integrated case management who informs you the patient “does not meet criteria” for
inpatient admission and must therefore be admitted under observation status. You are busy
with other admissions and you have no idea what “criteria” they are talking about so you
meekly nod your head and agree to make the changes as instructed.
SCENARIO 2
You are a cardiologist called in at 3:00 a.m. for an urgent consult on a Medicare
patient being admitted under observation status with chest pain. The patient had been seen
once in the office by one of your partners for pre-op clearance prior to knee surgery approximately
two years ago. For the current encounter, the patient requires high complexity medical
decision-making. You also perform a comprehensive history and a comprehensive exam.
SCENARIO 3
You are a nephrologist working at a hospital where all admissions are performed
by hospitalists. You get consulted at 3:00 a.m. to come in an perform “emergency dialysis” on
one of your group’s Medicare patients on chronic dialysis who has been admitted under observation
status. Because you are not personally familiar with the patient, you perform a comprehensive
history and a comprehensive physical exam. Although the patient is not critically ill, you
provide high complexity medical decision-making in order to decide whether or not you need to
call in the dialysis nurse from home to dialyze the patient.
