Form CMS-2746 ESRD Death Notification

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0448

ESRD DEATH NOTIFICATION
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
1. Patient’s Last Name

First

3. Patient’s Sex
a. ■ Male

MI

2. Medicare Claim Number

4. Date of Birth

5. Social Security Number

■■ _Month_ / _Day_ / _ _Year_ _

b. ■ Female

Month

6. Patient’s State of Residence

Day

Year

7. Place of Death
a.
b.

■ Hospital
■ Dialysis Unit

c.
d.

■ Home
e. ■ Other
■ Nursing Home

8. Date of Death

_ _ / _ _ / _ _ _ _
Month

Day

Year

9. Modality at Time of Death
a. ■ Incenter Hemodialysis

b. ■ Home Hemodialysis

c. ■ CAPD

d. ■ CCPD

e. ■ Transplant

10. Provider Name and Address (Street)

f. ■ Other

11. Provider Number

Provider Address (City/State)

12. Causes of Death (enter codes from list on back of form)
a. Primary Cause

_ _ _

b. Were there secondary causes?

■
■

No
Yes, specify:

_ _ _

_ _ _

_ _ _

_ _ _

■■

C. If cause is other (98) please specify:___________________________________________________________________

■ ■■■ ■■■ ■■■
13. Renal replacement therapy discontinued prior to death:

■ Yes

■

If yes, check one of the following:
a.

■ Following HD and/or PD access failure

b.

■ Following transplant failure

c.

■ Following chronic failure to thrive

d.

■ Following acute medical complication

e.

■ Other

f.

Date of last dialysis treatment

No 14. Was discontinuation of renal replacement
therapy after patient/family request to stop
dialysis?

■ Yes

■ No

■ Unknown

■ Not Applicable

_ _ / _ _ / _ _ _ _ ■■ ■■ ■■■■
Month

15. If deceased ever received a transplant:
a. Date of most recent transplant _ _

Day

Year

/__/____

Month

b. Type of transplant received
■ Living Related
■ Living Unrelated

Day

■ Deceased

■ Unknown

16. Was patient receiving Hospice care prior
to death?

Year

■ Unknown

c. Was graft functioning (patient not on dialysis) at time of death?
■ Yes
■ No
■ Unknown

■

Yes

■

No

■ Unknown

d. Did transplant patient resume chronic maintenance dialysis prior to death?
■ Yes
■ No
■ Unknown
17. Name of Physician

(Please print complete name)

18. Signature of Person Completing This Form

Date

This report is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). Individually identifiable patient information will not be
disclosed except as provided for in the Privacy Act of 1974 (5 U.S.C. 5520; 45 CFR Part 5a).
Form CMS-2746-U3 (01/04)

ESRD DEATH NOTIFICATION FORM
LIST OF CAUSES
CARDIAC
23 Myocardial infarction, acute
25 Pericarditis, incl. Cardiac tamponade
26 Atherosclerotic heart disease
27 Cardiomyopathy
28 Cardiac arrhythmia
29 Cardiac arrest, cause unknown
30 Valvular heart disease
31 Pulmonary edema due to exogenous fluid
32 Congestive Heart Failure
VASCULAR
35 Pulmonary embolus
36 Cerebrovascular accident including
intracranial hemorrhage
37 Ischemic brain damage/Anoxic encephalopathy
38 Hemorrhage from transplant site
39 Hemorrhage from vascular access
40 Hemorrhage from dialysis circuit
41 Hemorrhage from ruptured vascular aneurysm
42 Hemorrhage from surgery (not 38, 39, or 41)
43 Other hemorrhage (not 38-42, 72)
44 Mesenteric infarction/ischemic bowel
INFECTION
33 Septicemia due to internal vascular access
34 Septicemia due to vascular access catheter
45 Peritoneal access infectious complication, bacterial
46 Peritoneal access infectious complication, fungal
47 Peritonitis (complication of peritoneal dialysis)
48 Central nervous system infection (brain abscess,
meningitis, encephalitis, etc.)
51 Septicemia due to peripheral vascular disease,
gangrene
52 Septicemia, other
61 Cardiac infection (endocarditis)
62 Pulmonary infection (pneumonia, influenza)
63 Abdominal infection (peritonitis (not comp of PD),
perforated bowel, diverticular disease, gallbladder)
70 Genito-urinary infection (urinary tract infection,
pyelonephritis, renal abscess)

LIVER DISEASE
64 Hepatitis B
71 Hepatitis C
65 Other viral hepatitis
66 Liver-drug toxicity
67 Cirrhosis
68 Polycystic liver disease
69 Liver failure, cause unknown or other
GASTRO-INTESTINAL
72 Gastro-intestinal hemorrhage
73 Pancreatitis
75 Perforation of peptic ulcer
76 Perforation of bowel (not 75)
METABOLIC
24 Hyperkalemia
77 Hypokalemia
78 Hypernatremia
79 Hyponatremia
100 Hypoglycemia
101 Hyperglycemia
102 Diabetic coma
95 Acidosis
ENDOCRINE
96 Adrenal insufficiency
97 Hypothyroidism
103 Hyperthyroidism
OTHER
80 Bone marrow depression
81 Cachexia/failure to thrive
82 Malignant disease, patient ever on
Immunosuppressive therapy
83 Malignant disease (not 82)
84 Dementia, incl. dialysis dementia, Alzheimer's
85 Seizures
87 Chronic obstructive lung disease (COPD)
88 Complications of surgery
89 Air embolism
104 Withdrawal from dialysis/uremia
90 Accident related to treatment
91 Accident unrelated to treatment
92 Suicide
93 Drug overdose (street drugs)
94 Drug overdose (not 92 or 93)
98 Other cause of death
99 Unknown

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0448. The time required to complete this information collection is estimated to
average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-2746-U3 (01/04)