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2	CMS FORMS TRAINING
3	What is the Network? A non-profit corporation operating under contract with the Centers for Medicare and Medicaid Services (CMS) Established to assist in the improvement of the quality of health care services and quality of life for dialysis and transplant patients Currently 18 Networks
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5	Western Pacific Renal Network Providing leadership and resources to renal professionals Providing information about End Stage Renal Disease Helping patients and facilities solve problems Assisting patients and facilities in disaster preparedness Collecting data to help monitor medical outcomes for quality improvement activities Maintaining the renal registry of ESRD patients for CMS
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7	Rules To Remember When Completing CMS - Forms
8	DO NOT LEAVE ANY FIELD BLANK!
9	CMS 2728 ESRD Medical Evidence Report
10	CMS 2728 – ESRD Medical Evidence Report WHEN TO SUBMIT When a Patient has been determined to be chronic ESRD and requires a regular course of dialysis or kidney transplant to maintain life If a patient goes from Incenter Hemodialysis to any home modality or receives a kidney transplant within 90 days of original onset of ESRD to request the entitlement period be waived If a patient has been off of dialysis more than 12 Months post recovered function event If a patient returns to dialysis following a transplant that has functioned for more than 36 months
11	CMS 2728 – ESRD Medical Evidence Report WHEN NOT TO SUBMIT If a patient is ACUTE, not chronic ESRD If a patient changes from any home modality to another home modality within the first 90 days If a patient on any home modality receives a transplant within the first 90 days If a patient returns from dialysis from a transplant that functioned less than 36 months If a patient returns to dialysis less than one year from a recovered function event
12	"PART A" PART A Checkboxes for Form Type Initial All Patients will only have one Re-Entitlement Patient may have more than one Supplemental Patient will only have one, if any
13	2728 – Fields 1-5 Please print name legibly If no Medicare # please enter N/A If no SSA, Make sure you indicate this on form Please enter MAILING address Please indicate if address is Nursing Home or other institution.
14	2728 – Fields 8 - 10
15	Part A Continued Applying for Medicare Coverage (Field 11) Medical Coverage (Field 12) Mandatory field – DO NOT LEAVE BLANK Height and Weight (Fields 13-14) Mandatory field – DO NOT LEAVE BLANK Use only whole numbers – no decimals If Amputee – enter height prior to amputation
16	Part A Continued Primary Diagnosis (Field 15) Mandatory – Must use codes on back of form Employment Status(Field 16) Mandatory – Must enter one in BOTH columns Co-Morbid Conditions (Field 17) Mandatory – if “None” you must check “None” If you check – U-Other Institution, you must also check one, 1-3.
17	Part A Continued Pre-ESRD Therapy (Field 18)
18	Part A Continued Laboratory Values (Field 19) Must be Within 45 days PRIOR to most recent ESRD episode Lipid Profile Must be Within 1 year (Item e)
19	2728 PART B CONTINUED Field 20 NAME OF YOUR FACILITY Not just corporate name or number Field 21 Medicare ESRD Provider Number CALIFORNIA 6 digit number starting with 05 or 55 Hawaii 6 digit number starting with 12
20	Part B for all Dialysis Patients Primary Dialysis Setting (Field 22) Use “Long Term Expected Modality” Primary Type of Dialysis (Field 23) Hemodialysis MUST complete sessions per week and hours per session for all Hemodialysis patients Patient been informed of Transplant Options (Field 26) If NO – MUST complete field 27
21	Part C –Kidney Transplant Information Complete only on Re-Entitlement form for patients returning to Dialysis after a transplant failure If patient is unable to provide the information for part C, you may contact the Network Office for the information. Type of Donor (Field 35) Deceased (Cadaveric) Living Related Living Unrelated
22	PART D – HOME TRAINING For patients completing Home Dialysis Training If onset modality, include on “Initial” 2728 If going from Hemo to a home modality within the first 90 days AND applying for Medicare. This type of form should be marked “Supplemental.” Physician MUST sign both field 44 AND 51.
23	PART e – Signatures Physician Attestations MUST be signed by Physician (Nephrologist) Patient Signature: Must be signed by patient or patient representative.
24	Network Patient Activity Report NPAR Monthly by 10^th
25	Network Patient Activity Reports Requires Patient Zip Code on additions Requires Patient Gender Requires date of event and modality Provides Space for Summary of Additions, Losses and Neutral Event Totals
26	Network Patient Activity Report Please make sure you enter the correct provider Print your name and enter phone number. Remember to write legibly! Or use the excel version.
27	PAR: Additions 1 = NEW = never on chronic ESRD 2728 required 2 = transfer from another provider 2a = from another Medicare certified provider 2b = from outside Medicare system 2728 required Prison, out of country 3 = restart (after recovery episode) 4 = dialysis after permanent kidney transplant failure
28	PAR: Losses 5 = transfer out for transplant 5a US transplant center 5b out of country 6 = transfer out 6a = to another Medicare certified unit 6b = prison, out of country (specify) 6c = INVOLUNTARY Discharge You will be contacted for reason
29	PAR: Losses 7 = discontinue:voluntarily stop treatment 2746 required if death within 30 days 8 = death = 2746 required 9 = recovery of kidney function Cannot follow 4 10 = Lost to follow up RARE
30	PAR: Neutral events 11 = modality change WITHIN your facility 15 = interruption in service Hospitalization, rehab, snf > 30 days Patient still on your census but inactive 16 = resume service When patient returns from 15
31	CMS 2746 DEATH NOTIFICATION effective October 1, 2004
32	2746 – Field 12
33	2746 – Field 13 and 14 IF YOU CHECK YES, you MUST: Check one (1) a – e (reason for discontinuation of dialysis) Complete f (Date of last treatment) Complete Field 14 (allows for unknown) This field is the most common error on the 2746.
34	2746 – 15 to 18
35	CMS 2746 – DEATH NOTIFICATION Must be Submitted for any active patient at facility at time of death. Due in Network office within 30 days of date of death. Also Required if death occurs within 30 days of last treatment at facility when patient chooses to discontinue dialysis treatment or if no other Medicare facility admits patient.
36	Where to Get CMS Forms CMS 2746 – ESRD Death Notification Contact the Network office to request or look for the link on the Network website (www.esrdnet17.org) CMS 2728 – ESRD Patient Registration Contact your local Social Security Office Network Patient Activity Report Contact the Network Office to request
37	IF THERE IS ONe THING We WANT YOU TO REMEMBER FROM TODAY’S PRESENTATION . . .
38	DO NOT LEAVE ANY FIELD BLANK!
39	CONTACT INFORMATION Susan Tanner Director of Information Systems Peter Traub Data Specialist Anne Brush Data Specialist Phone: 415-897-2400 Susan x 106 Peter x 104 Anne x 103 Data fax 415-897-2443 http://www.esrdnet17.org Email cannot be used for patient specific information