The CMS 2728 must be signed by the treating physician (MD or DO) who is knowledgeable of his/her kidney failure.
What form of data does the CMS 2728 form collect?
Aside from the expected patient demographics, form 2728 collects various diagnostic and care information, for example, primary and secondary diagnoses leading to ESRD status (boxes 14 and 16), aspects of pre-dialysis chronic kidney disease (CKD) care (box 17), and incident laboratory data (box 18) (3).
What is the purpose of a 2728 form?
Timely 2728 form submission directly impacts a dialysis facilitys QIP (Quality Incentive Program) score and potential reimbursement amount. Required for all new ESRD patients within 45 days of their first treatment. The 2728 form should NOT be completed for AKI (Acute Kidney Inquiry) patients.
What is the purpose of Form 2728?
The 2728 form is required by CMS for all ESRD patients pertaining to Medicare entitlement eligibility and/or for patient registration purposes (even if a patient is not applying for Medicare benefits).
How do I submit form 2728?
2728 Forms are submitted in EQRS: . Submitted within 45 days of the Admit Date (Field 24).
form 2728
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Do you automatically qualify for Medicare if on dialysis?
People with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) of all ages are eligible for Medicare coverage. People with ESRD can choose either Original Medicare or a Medicare Advantage Plan when deciding how to get Medicare coverage.
printable 2728 form
Appendix A. CMS-2728 Medicare Eligibility Form
To be completed by the attending physician. Enter the ICD-. 9-CM from back of form to indicate the primary cause of end stage renal disease. These
Specify in the order details: This is for a kidney transplant evaluation. Please assess aorta, IVC and iliac vessels for patency. Laboratory evaluation of
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