Home>
Professionals > Data Collection
Data Collection
Medical
Evidence Report (2728 Form)
The
2728 is required for all first-time chronic dialysis patients; required
for all patients initially receiving kidney transplant instead of dialysis;
required for patients who stopped dialysis for more than 12 months,
or for patients who a had functioning transplant for over 3 years but
are now returning to dialysis or are receiving another transplant.
The
green copy should be submitted to Network #17 within 45 days of patient's
first course of "regular dialysis" at the chronic facility,
or 45 days after patient receives a transplant. In some cases the 2728
is completed by an acute care hospital that also does chronic dialysis
treatment. HOWEVER, it is the ultimate responsibility of the chronic
outpatient dialysis facility to ensure that such a form has been completed
and mailed to Network #17. The blue copy goes to Social Security.
Revised
2728
At this time ONLY the newest version of the 2728 (dated EF 03/2005 at
the bottom of form) will be accepted by Network #17. If you run out
of these new forms you may get more from your local Social Security
office. In the meantime, you may use this online 2728 (pdf 4 pgs) -
but be sure to have the doctor sign this electronically-generated form
in BLUE INK. Send the original form with the signatures in blue ink
to Social Security.
-
Note:
Numbers 18a-c of the new 2728 asks about time-frames for pre-dialysis
therapies given to patients. The 2728 does not offer the choice
0-6 months prior to dialysis. If this is the correct answer, we
ask that you hand write 0-6 on the 2728 form next to the "yes"
box.
-
Note:
Number 18d must be completed for all hemodialysis patients.
If the type of access is catheter or graft, you must answer the
two sub-questions (is a maturing AVF or graft present).
-
Note: For every patient that is on "incenter-hemodialysis"
you MUST indicate the frequency and duration of dialysis treatments
for question 23.
GFR
Calculators
2005
Algorithm for GFR (pdf - 1 pg) - This summarizes the CMS criteria to
determine eligibility for the ESRD program and should be used when determining
the chronic status of a patient. The GFR value does not need to go on
the 2728 form, but should be calculated to ensure that 2728 forms are
submitted only for truly chronic patients.
Below
are additional resources regarding the basis for the MDRD formula and
how to calculate a GFR using this formula:
www.nkdep.nih.gov/GFR-cal.htm
www.hdcn.com/calcf/gfr.htm
http://nephron.com/mdrd/default.html
www.kidney.org (K/DOQI
Clinical Practice Guideline Tab) - Has downloadable GFR calculator
and CKD Clinical Action Plan
Back to top
Death
Notification Form (2746)
Death
Notification Form (CMS Form
2746) (pdf
- 2 pgs) - You may download and use this form --and remember
there is no need to send more than one copy of a 2746 to Network #17,
and you do NOT need to send the second sheet (codes).
The
2746 should
be submitted within 30 days of death by last facility responsible for
permanent chronic dialysis. If patient has discontinued dialysis and
dies within 30 days, the last chronic dialysis facility is still
required to submit a 2746. If patient's last event was a transplant,
the transplant clinic is responsible for submitting 2746.
Back to top
Network
Patient Activity Report (NPAR)
This NPAR was revised in June of 2005.
All NPARs
should be faxed to Network #17 by the 10th day of the month. NEVER
email NPARs (or any other patient information). The following NPAR
documents will be available soon to downloaded if you need extra copies:
Guidelines
to follow when completing the NPAR:
Top
Portion of the Report
- Enter your
facility's Provider Number (the Medicare number assigned to you
by CMS), your Provider Name (the name of your facility), the Reporting
Month (the month in which activities occurred), and your facility's
telephone number.
- Be sure to
print your name on the form so we know who to contact if we have
questions.
- You do not
need to do anything with the "Activity Summary" section.
Reporting
Activities
- Enter the patient's
Last Name and First Name, Social Security Number, Date of Birth,
Gender, and ZIP Code.
- Enter the date
of the activity you are reporting.
- Record the
specific type of event under the appropriate category for additions,
losses, or neutral events. Note: We have added 5B - "Transfer
Out for Transplant outside of US"
- If the event
is an addition or modality change, be sure to include what type
of treatment (Modality) you are providing.
- If you are
reporting a Transfer In or Transfer Out, enter the provider number,
name, or city and state (or country) of the facility from which
the patient has come or to which he/she is going.
- Remember that
neutral events (numbers 11, 15, and 16) do not change your facility's
overall population.
Back to top
Transplant
Activity Report (TAR)
Each
transplant facility in Network #17 needs to turn in a TAR every month
to report all kidney transplants that have taken place. The TAR should
be faxed to 415-897-2443
and is due by the 10th of the month. The TAR should NEVER be emailed.
- TAR
- in Microsoft Word so that you may save it and type directly onto
the form or make a copy to write on.
- You may generate
a report out of your own data system as long as it contains the required
elements on the TAR form.
Please call if
you need more information about doing this.
Back to top
Network
#17 Reports That are Sent to Dialysis Facilities
Compliance
Reports - (aka: Timeliness and Accuracy Reports) CMS mandates that
90% of required forms (2746s and 2728s) are submitted on time and complete.
This report shows the percentage of forms received that meet this standard.
Report is sent to facilities semiannually and is reviewed by CMS to
determine if sanctions against facilities are warranted.
Missing
Forms Report - 2746 missing forms report is sent monthly at first
of month. The 2728 missing forms report is sent monthly about 15th of
month. Forms may appear on a report for two months; after that a letter
requesting the form is sent to unit administrator.
Quarterly
Roster - Alphabetical list of patients the Network shows to be currently
dialyzing at a facility (grouped by modality.) Sent out quarterly, the
roster needs to be reviewed by the facility and returned with a list
of any additions, losses, or modality changes.
CMS
Data Element Reconciliation Report: Sent when there is a discrepancy
between patient data at the Network and at CMS. The date elements include
first name, last name, birth date, Social Security number. The report
must be returned within five working days.
Back to top
Frequently Asked Questions
Q:
The State Survey Agency has assigned our unit a provider number with
"23" as the middle number, but Network #17 is telling us not
to use this number. Why?
A: CMS has issued this letter confirming the policy requiring hospital-based
units to use their hospital provider number with 00-08 in the middle
rather than the "23" in all correspondence with the ESRD Networks
or CMS.
Q:
What happens if a patient enters a long-term care center (i.e. VENCOR)
or a hospital?
A: That event is now considered an "Interruption in Service"
and may be reported via the Network Patient Activity Report. That patient
is still considered a part of the population, and any status change
(death, recover function, transfer to chronic facility) needs to be
reported via the NPAR.
Q:
Where do facilities obtain blank 2728 and 2746 forms?
A: Local Social Security offices have blank 2728 forms. The Network
has blank 2746 forms, or, better yet, you may download the 2746
form here.
Q:
Do facilities need to attach copies of death certificates to 2746 forms?
A: No.
Q.
Can facilities fax forms?
A: Yes. If you fax both forms. If you fax, do not mail a copy of
the same form.
Back to top

505
San Marin Dr. Bldg. A, Suite 300, Novato, CA 94945
Phone: 415-897-2400
Administration Fax: 415-897-2422
Data Fax: 415-897-2443
Home