CMS Form 2728ESRD 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.

Date of birth is a required field.

CMS 2728Fields 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.

CMS 2728Fields 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.

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.

CMS 2728Fields 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.

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.

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.

CMS 2728Fields 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.

CMS 2728Fields 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.

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.

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.

CMS 2746

Instructions for completion of the 2746 form

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.

CMS 2746

Field 7 You must select one option a – e

Field 8 The date of death is required

CMS 2746

Fields 9 – 11 This is information specific to the

facility that is needed.

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

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

CMS 2746

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

Field 16 Answer if applicable

CMS 2746Field 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.

CMS Form 2728/2746 Review Completed

You are now ready for the next step which is to review the

Root Cause Flowchart.