1. CMS Form 2728 ESRD 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
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. Instructions for completion of the 2746 form
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.