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Jump to general 2728 questions

1. On #18 a, b or c, how do I answer for patients with timeframes < 6 months?
2. There are new lab values on this form. Do I have to complete all of the lab values?
3. #19a3 Serum Albumin—what is “BCG or BCP?”
4. #19e Lipid Profile values—we often don’t get those for months after we first see the patient; what do you want us to do?
5. On the front of the form, #19 states “Lipid Profile can be within 1 year of the most recent ESRD episode.” However, the instructions for #19e state, "Lipid Profile . . . and date must be within 1 year prior to ..." —Which is it?
6. Why are the Lipid Profile values listed on the 2728?
7. # 51 Physician Recertification Signature--what is this?
8. Where do we obtain more 2728 forms?

Answers Regarding the 2005 Version of the 2728

1. On #18 a, b or c, how do I answer for patients with timeframes < 6 months?
   Answer: Unfortunately, the option for the 0-6 months timeframe is missing. If you need to report <6 months for #18 a, b or c, please write in “< 6 months” Top
2. There are new lab values on this form. Do I have to complete all of the lab values?
   Answer: Though 19b Serum Creatinine remains the only mandatory lab value (used to calculate GFR), we strongly encourage you to complete as many items as possible, as CMS uses this information in many important studies related to improving patient care. Top
3. #19a3 Serum Albumin—what is “BCG or BCP?”
   Answer: This refers to the type of dye used when obtaining the serum albumin, and the information should be available on the lab sheet next to the value. Top
4. #19e Lipid Profile values—we often don’t get those for months after we first see the patient; what do you want us to do?
   Answer: If you expect it will take more than 45 days to obtain these lab values, you should not hold the 2728 until you receive them. Please turn in your 2728 form as promptly as possible, even if 19e is left blank. However, please submit the lipid profile values whenever you obtain them. Again, CMS uses this information in many important studies related to improving patient care. Top
5. On the front of the form, #19 states “Lipid Profile can be within 1 year of the most recent ESRD episode.” However, the instructions for #19e state, "Lipid Profile . . . and date must be within 1 year prior to ..." —Which is it?
   Answer: Within 1 year prior to the first dialysis treatment or kidney transplant. Top
6. Why are the Lipid Profile values listed on the 2728
   Answer: There are now clinical practice guidelines for these markers and this data is being collected to gain insight into whether or not these are being done regularly on patients. “Healthy People 2010” and USRDS reports this data. Top
7. # 51 Physician Recertification Signature. What is this?
   Answer: This is for SSA purposes only. Please disregard this field. Top
8. Where do we obtain more 2728 forms?
   Answer: There are two ways to obtain blank 2728 forms: from your local Social Security Administration office, or download from the CMS Web_site.
   Important Note: if using a downloaded form, the SSA office must receive the original — with the physician’s signature in blue ink — per SSA requirements. You may submit a photocopy to Network 11. If a patient reports that the local SSA office will not accept the downloaded 2728, you may refer them to the SSA Organization Manual. Top

** If you are unable to obtain certain data elements or meet CMS required deadlines, please call your Network 11 Data Specialist to discuss options. They will consider the matter on a case-by-case basis, and ask you to put a note on the form you eventually submit to document the conversation. **

General Questions

Jump to questions regarding the NEW 2728

1. What is the purpose of the CMS-2728 (Medical Evidence) form, and why does it need to be completed for patients who choose not to enroll in Medicare?
2. When is a 2728 required?
3. When is a "Supplemental" or "Re-entitlement" 2728 form required?
4. If a "Supplemental" or "Re-entitlement" 2728 is required, does the patient have to sign this second form?
5. Where do I get Supplemental or Re-entitlement 2728 forms?
6. How do I get additional 2728 forms?
7. What if a patient dies before signing the 2728?
8. What if the patient is unable/unavailable to sign the 2728?
9. How long does our facility need to retain a copy of completed 2728 forms?
10. What is IPD (Field #22 on the 2728)?
11. What date do I use for #23 — Date Regular Dialysis Began?
12. What date do I use for #24 when a patient is on a home modality?
13. What date do I use for #38 — Date Training Began?
14. How do I correct an error on a 2728?

Answers

1. What is the purpose of the CMS-2728 (Medical Evidence) form, and why does it need to be completed for patients who choose not to enroll in Medicare?
   Answer: The 2728 form is required for all newly diagnosed ESRD patients, regardless of their Medicare status or treatment modality. The 2728 form serves two purposes: (1) Provide medical evidence of an end-stage renal condition for Medicare entitlement, and (2) Register a patient in a national renal registry. The form is sent to Network 11 where it is entered into a national database maintained by Centers for Medicare and Medicaid Services (CMS). CMS provides the data to the United States Renal Data System (USRDS) for scientific research. The information on the 2728 is highly confidential. It is important in aiding caregivers and assuring quality care for ESRD patients. Top
2. When is a 2728 required?
   Answer: When a patient is diagnosed as ESRD and receives their first transplant or outpatient dialysis treatment(s). Top
3. When is a "Supplemental" or "Re-entitlement" 2728 form required?
   Answer: A supplemental 2728 form is required when an initial 2728 form has been previously submitted to Network 11 and the patient: Top
   • Transitions to any type of home dialysis within the first 3 months after initial dialysis
   • Has a transplant within the first 3 months after initial dialysis
   A re-entitlement 2728 form is required when a patient resumes treatment after benefits have expired; that is, when the patient:
   • Restarts dialysis after 1 year or more of having recovered function or discontinued dialysis
   • Restarts dialysis after 3 years or more following a transplant
   • Has another transplant, 3 years or more following a transplant, with no dialysis in between
4. If a "Supplemental" or "Re-entitlement" 2728 is required, does the patient have to sign this second form?
   Answer: Yes. This ensures continuing medical coverage for the patient. Top
5. Where do I get Supplemental or Re-entitlement 2728 forms?
   Answer: There is not a separate form for Supplemental 2728s. Complete a new 2728 using the standard form. Check the appropriate box at the top of the form. Top
6. How do I get additional 2728 forms?
   Answer: There are two ways to obtain blank forms: contact your local SSA office, or download from the CMS Web site.
   Important Note: if using a downloaded form, the SSA office must receive the original — with the physician’s signature in blue ink — per SSA requirements. You may submit a photocopy to Network 11. If a patient reports that the local SSA office will not accept the downloaded 2728, you may refer them to the SSA Organization Manual. Top
7. What if a patient dies before signing the 2728?
   Answer: Enter the date of death in Field #26 and send the form to the Network 11 office. Top
8. What if the patient is unable/unavailable to sign the 2728?
   Answer: A signature is required by CMS, you may need to mail a copy of the form to the patient’s home. A spouse, parent, sibling or adult child may sign on the patient’s behalf. No power of attorney is required for signing the 2728. Top
9. How long does our facility need to retain a copy of completed 2728 forms?
   Answer: Each facility determines how long they keep forms, depending on their individual office policy. At Network 11, we keep 2728 forms on file for five years after a patient's death. Top
10. What is IPD (Field #22 on the 2728)?
    Answer: IPD is Peritoneal Dialysis that is performed 3 times per week at a dialysis facility (not at the patient's home). This is a selection in Field #22 on the 2728.Top
11. What date do I use for #23 – Date Regular Dialysis Began?
    Answer: Use the date of the first dialysis treatment patient received, regardless of setting (i.e. if patient received dialysis inpatient, use that date). If this is a "Supplemental" Form, use the date related to the most recent episode. Top
12. What date do I use for #24 when a patient is on a home modality?
    Answer: Usually, this will be the date training begins. *See Question 13. Top
13. What date do I use for #38—Date Training Began?
    Answer: The official date training begins is the date of the first dialysate exchange (even if only a partial, as part of training). Flushes and other training do not count. Top
14. How do I correct an error on a 2728?
    Answer: You may phone in the corrected information to your Network 11 Data Contact, or you may fax a corrected 2728 to the Network 11 office. Do not send patient information to Network 11 via e-mail.

** If you are unable to obtain certain data elements or meet CMS required deadlines, please call your Network 11 Data Specialist to discuss options. They will consider the matter on a case-by-case basis, and ask you to put a note on the form you eventually submit to document the conversation. **