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Revised 2728 Eligibility Process

With assistance from the Forum of ESRD Networks, CMS has revised its process for determining eligibility for the ESRD Medicare program based on GFR. The change responds to K/DOQI guidelines that recommend the timing for initiation of renal replacement therapy should be determined by the glomerular filtration rate (GFR) and the presence of uremic symptoms. Previously, eligibility was based on serum creatinine and creatinine clearance values. Network 11 reviewed any patients who did not meet the criteria to determine the appropriateness of treatment.

Effective July 1, 2003, CMS has directed the Networks to review facility profiles—rather than individual patients—to ensure that providers are initiating renal replacement therapy appropriately. These reviews are to occur at least annually, but may be done more frequently if needed. The profiles will be based on patient GFRs calculated from lab values reported on the 2728 forms. The Network 11 Medical Review Committee (MRC) will review facilities and physicians with greater than 10% of incident patients having a GFR that is more than two standard deviations from the mean of all incident patients.

For adults, GFRs will be calculated based on the formula used in the Modification of Diet in Renal Disease Study (MDRD). The Schwartz Formula will be applied for patients 18 years old or younger. The mean GFR for incident patients will be calculated each year for the profile reports. For example, the mean GFR for incident patients in 2001 was 9.56 ml/min/1.73m2 for adults, and 13.14 ml/min/1.73m2 for pediatric patients. The GFR value two standard deviations from the mean for incident adult and pediatric patients in 2001 was 24.71 ml/min/1.73m2 and 34.91 ml/min/1.73m2, respectively. Therefore, facilities and providers having greater than 10% of adult patients with a GFR > 25 ml/min/1.73m2 or pediatric patients with a GFR > 35 ml/min/1.73m2 in 2001 would trigger a review by the MRC.

Click to view a PDF (46 KB PDF file opens in new browser) containing information on this review process, including the MDRD and Schwartz Formulas for calculating GFRs.

If you have questions regarding this process, please contact Jan Deane at the Network 11 office (651) 644-9877 or email jdeane@nw11.esrd.net.

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