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CMS Form 2728 ESRD Medical Evidence Report

CMS Form 2728 ESRD Medical Evidence Report. Instructions for completing the 2728. 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.

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CMS Form 2728 ESRD Medical Evidence Report

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  1. CMS Form 2728ESRD Medical Evidence Report Instructions for completing the 2728

  2. 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.

  3. CMS 2728 Fields 5 – 10 • The patient’s 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.

  4. CMS 2728 Fields 12 - 15 • The patient’s 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.

  5. 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.

  6. CMS 2728 Fields 18a – 18c • If you answer yes, you must select a timeframe of either 6 – 12 months, > 12 months or one that is not listed < 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. CMS 2728 Fields 46 – 53 Physician Identification • Always provide the physician’s name and UPIN. This information is needed when the signature is illegible. • The physician must sign line 49.

  12. 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.

  13. CMS 2746 Instructions for completion of the 2746 form

  14. 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.

  15. CMS 2746 Field 7 • You must select one option a – e Field 8 • The date of death is required

  16. CMS 2746 Fields 9 – 11 • This is information specific to the facility that is needed.

  17. 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

  18. 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

  19. CMS 2746 Field 15 • Answer a, b, c and d if applicable Field 16 • Answer if applicable

  20. 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.

  21. CMS Form 2728/2746 Review Completed You are now ready for the next step which is to review the Root Cause Flowchart.

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