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.
Who is the organization that processes Medicare claims for CMS?
Coordination of Benefits Overview The Medicare Administrative Contractors, (MACs), intermediaries, and carriers are responsible for processing claims submitted for primary or secondary payment and resolving situations where a provider receives a mistaken payment of Medicare benefits.
Who fills out CMS 2728?
The CMS 2728 must be signed by the treating physician (MD or DO) who is knowledgeable of his/her kidney failure.
What is a 2728 form for?
Form CMS-2728 Overview Form CMS-2728 is the ESRD Medical Evidence Report Medicare Entitlement and/or Patient Registration and must be: Entered in the ESRD Quality Reporting System (EQRS) within 45 days of the patient starting on chronic dialysis at the facility.
Who completes a 2728 form?
Question 7: Who at the facility should complete the Form CMS-2728? Answer: Per the form instructions, the form is to be completed by the attending physician, head nurse, or social worker involved in the patients treatment. The Facility should determine the most appropriate individual(s) to complete the form in EQRS.
2728 form pdf
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2728 Forms are submitted in EQRS: . Submitted within 45 days of the Admit Date (Field 24).
What is the Medicare application form for ESRD?
The Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) is the primary documentation that a claimant has ESRD. It also provides statistical data for use in monitoring the ESRD program.
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).
2728 esrd 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
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