CMS Form 2728 ESRD Medical Evidence Report

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CMS Form 2728ESRD Medical Evidence Report

• Instructions for completing the 2728

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CMS 2728

• Check type of form initial, re-entitlement or
  supplemental.
• Fields 1 - 4
• Patients legal name is required.
• Medicare and social security numbers are
  requested but not required.
• Date of birth is a required field.

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CMS 2728

• Fields 5 10
• The patients complete mailing address is
  required as well as the sex and ethnicity.
• The country of origin is required if Native
  Hawaiian or Other Pacific Islander is the race.
• The race is required for all patients. You must
  select at least one race code for Hispanic
  patients.

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CMS 2728

• Fields 12 - 15
• The patients current medical coverage is
  required.
• The height is required even if the patient is a
  bilateral amputee. Use the height prior to
  amputation in this case.
• The dry weight is required.
• The primary cause is required and only the codes
  listed on the form can be used.

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CMS 2728

• Fields 16 and 17
• Employment status is requested and both columns
  should be checked.
• Co-morbid conditions you should check all that
  apply.

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CMS 2728

• Fields 18a 18c
• If you answer yes, you must select a timeframe of
  either 6 12 months, gt 12 months or one that is
  not listed lt 6 months.
• Field 18d
• If you select catheter as the first access used
  as an outpatient, you must answer the two sub
  questions.
• If you select graft as the first access used as
  an outpatient, you must answer the first sub
  question.

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CMS 2728

• Field 19
• Lab Values The serum creatinine is the only
  required lab and should be within 45 days prior
  to the date regular chronic dialysis began.
• If the other labs are provided they must be
  within the specified guidelines.

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CMS 2728

• Fields 20 27
• Complete for all patients in dialysis treatment.
• If the patient is on hemodialysis, you must
  provide the sessions per week and the hours per
  session.
• If the patient has not been informed of kidney
  transplant options, you must select the reason(s)
  why in field 27.

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CMS 2728

• Fields 28 37 Section C
• Complete for all Kidney Transplant Patients
• If you are unsure of the Medicare provider
  number(fields 30 and 33) for transplant
  facilities, contact the Network for assistance.
• Field 36 should be the same date as field 24 if
  the patient is returning to dialysis following
  the failure of a transplant.

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CMS 2728

• Fields 38 45 Section D
• Complete for all ESRD Self-Dialysis Training
  Patients
• The date training began can be no more than 30
  days prior to the date the patient started at
  your facility.
• If the patient is unable to complete training,
  this section should not be completed and a home
  dialysis setting should not be chosen.
• The physician must sign in field 44B.

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CMS 2728

• Fields 46 53 Physician Identification
• Always provide the physicians name and UPIN.
  This information is needed when the signature is
  illegible.
• The physician must sign line 49.

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CMS 2728

• Fields 54 and 55
• The patient or his/her representative must sign
  and date here.
• If the patient dies before a signature can be
  obtained, submit without a signature and provide
  the date of death.

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CMS 2746

• Instructions for completion of the 2746 form

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CMS 2746

• Fields 1 6
• The basic demographic data of name, Medicare
  number, sex, date of birth, SSN and state of
  residence is needed to correctly identify the
  patient.

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CMS 2746

• Field 7
• You must select one option a e
• Field 8
• The date of death is required

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CMS 2746

• Fields 9 11
• This is information specific to the facility that
  is needed.

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CMS 2746

• Field 12
• The primary cause of death is required and you
  must choose from the codes listed on the form.
• If code 98 is used, you must provide a narrative
  in field 12c.
• Provide a secondary code if available

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CMS 2746

• Field 13
• If answered yes, you must selection one of
  options a e and provide the date of last
  dialysis in field 13f.
• Field 14
• Answer if applicable

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CMS 2746

• Field 15
• Answer a, b, c and d if applicable
• Field 16
• Answer if applicable

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CMS 2746

• Field 17
• Only the name of the physician is required, not a
  signature. The name must be legible.
• Field 18
• The name of the person completing the form should
  be provided in this field.

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CMS Form 2728/2746 Review Completed

• You are now ready for the next step which is to
  review the
• Root Cause Flowchart.