Form CMS-2728 End State Renal Disease Medical Evidence Report

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

Form Approved

OMB
No.
0938-0046
0938-0046

OMB
No.
XXXX-XXXX

END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT

MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION

A. COMPLETE FOR ALL ESRD PATIENTS

Check one:

Initial

Re-entitlement

Supplemental

1. Name (Last, First, Middle Initial)
2. Medicare Claim Number

3. Social Security Number

4. Date of Birth (mm/dd/yyyy)

5. Patient Mailing Address (Include City, State and Zip)

6. Phone Number (including area code)

7. Sex

9. Country/Area of Origin or Ancestry

8. Ethnicity

Male
Female
Not Hispanic or Latino
10. Race (Check all that apply)
White
Black or African American
American Indian/Alaska Native

Hispanic or Latino (Complete Item 9)
Asian
Native Hawaiian or Other Pacific Islander*

11. Is patient applying for
ESRD Medicare coverage?
Yes

No

*complete Item 9

Print Name of Enrolled/Principal Tribe ______________________________

12. Current Medical Coverage (Check all that apply)
13. Height
Medicaid
Medicare
Employer Group Health Insurance INCHES ______ OR
DVA
Medicare Advantage
Other
None
CENTIMETERS ______

Pr

io
Cu r
rr
en

t

16. Employment Status (6 mos prior and
current status)

Unemployed
Employed Full Time
Employed Part Time
Homemaker
Retired due to Age/Preference
Retired (Disability)
Medical Leave of Absence
Student

14. Dry Weight

15. Primary Cause of Renal
Failure (Use code from back of form)

POUNDS ______ OR
KILOGRAMS ______

17. Co-Morbid Conditions (Check all that apply currently and/or during last 10 years) *See instructions
a.
Congestive heart failure
n.
Malignant neoplasm, Cancer
b.
Atherosclerotic heart disease ASHD
o.
Toxic nephropathy
c.
Other cardiac disease
p.
Alcohol dependence
d.
Cerebrovascular disease, CVA, TIA*
q.
Drug dependence*
e.
Peripheral vascular disease*
r.
Inability to ambulate
f.
History of hypertension
s.
Inability to transfer
g.
Amputation
t.
Needs assistance with daily activities
h.
Diabetes, currently on insulin
u.
Institutionalized
i.
Diabetes, on oral medications
1. Assisted Living
j.
Diabetes, without medications
2. Nursing Home
k.
Diabetic retinopathy
3. Other Institution
l.
Chronic obstructive pulmonary disease v.
Non-renal congenital abnormality
w.
None
m.
Tobacco use (current smoker)

18. Prior to ESRD therapy:
a. Did patient receive exogenous erythropoetin or equivalent?
b. Was patient under care of a nephrologist?
c. Was patient under care of kidney dietitian?
d. What access was used on first outpatient dialysis:
If not AVF, then: Is maturing AVF present?
Is maturing graft present?

Yes
Yes
Yes
AVF
Yes
Yes

No
No
No
Graft
No
No

Unknown
Unknown
Unknown
Catheter

If Yes, answer:
If Yes, answer:
If Yes, answer:
Other

6-12 months
6-12 months
6-12 months

>12 months
>12 months
>12 months

19. Laboratory Values Within 45 Days Prior to the Most Recent ESRD Episode. (Lipid Profile within 1 Year of Most Recent ESRD Episode).

LABORATORY TEST

VALUE

DATE

LABORATORY TEST

a.1. Serum Albumin (g/dl)

___ . ___

d. HbA1c

a.2. Serum Albumin Lower Limit

___ . ___

e. Lipid Profile

a.3. Lab Method Used (BCG or BCP)

VALUE

DATE

___ ___ . ___%
TC

___ ___ ___

LDL

___ ___ ___

b.

Serum Creatinine (mg/dl)

___ ___ . ___

HDL

c.

Hemoglobin (g/dl)

___ ___ . ___

TG

___ ___
___ ___ ___ ___

B. COMPLETE FOR ALL ESRD PATIENTS IN DIALYSIS TREATMENT
20. Name of Dialysis Facility

21. Medicare Provider Number (for item 20)

22. Primary Dialysis Setting

23. Primary Type of Dialysis

Home

Dialysis Facility/Center

SNF/Long Term Care Facility

24. Date Regular Chronic Dialysis Began (mm/dd/yyyy)
26. Has patient been informed
of kidney transplant options?
Yes

No

FORM CMS-2728-XX-XXX
CMS-2728-U3 (03/06)

Hemodialysis (Sessions per week____/hours per session____)
CAPD
CCPD
Other
25. Date Patient Started Chronic Dialysis at Current Facility (mm/dd/yyyy)

27. If patient NOT informed of transplant options, please check all that apply:
Medically unfit
Patient has not been assessed

Patient declines information
Psychologically unfit

Unsuitable due to age
Other
1

C. COMPLETE FOR ALL kIDNEY TRANSPLANT PATIENTS
28. Date of Transplant (mm/dd/yyyy)

29. Name of Transplant Hospital

30. Medicare Provider Number for Item 29

Date patient was admitted as an inpatient to a hospital in preparation for, or anticipation of, a kidney transplant prior to the
date of actual transplantation.
31. Enter Date (mm/dd/yyyy)

32. Name of Preparation Hospital

34. Current Status of Transplant (if functioning, skip items 36 and 37)
Functioning

Non-Functioning

33. Medicare Provider number for Item 32

35. Type of Donor:
Deceased

Living Related

Living Unrelated

36. If Non-Functioning, Date of Return to Regular Dialysis (mm/dd/yyyy) 37. Current Dialysis Treatment Site
Home

Dialysis Facility/Center

SNF/Long Term Care Facility

D. COMPLETE FOR ALL ESRD SELF-DIALYSIS TRAINING PATIENTS (MEDICARE APPLICANTS ONLY)
38. Name of Training Provider

39. Medicare Provider Number of Training Provider (for Item 38)

40. Date Training Began (mm/dd/yyyy)

41. Type of Training
Hemodialysis a.
CAPD
CCPD

42. This Patient is Expected to Complete (or has completed) Training
and will Self-dialyze on a Regular Basis.
Yes

Home b.
Other

In Center

43. Date When Patient Completed, or is Expected to Complete, Training
(mm/dd/yyyy)

No

I certify that the above self-dialysis training information is correct and is based on consideration of all pertinent medical, psychological, and
sociological factors as reflected in records kept by this training facility.
44. Printed Name and Signature of Physician personally familiar with the patient’s training
a.) Printed Name

b.) Signature

45. UPIN of Physician in Item 44

c.) Date (mm/dd/yyyy)

E. PHYSICIAN IDENTIFICATION
46. Attending Physician (Print)

47. Physician’s Phone No. (include Area Code)

48. UPIN of Physician in Item 46

PHYSICIAN ATTESTATION
I certify, under penalty of perjury, that the information on this form is correct to the best of my knowledge and belief. Based on diagnostic
tests and laboratory findings, I further certify that this patient has reached the stage of renal impairment that appears irreversible and
permanent and requires a regular course of dialysis or kidney transplant to maintain life. I understand that this information is intended for
use in establishing the patient’s entitlement to Medicare benefits and that any falsification, misrepresentation, or concealment of essential
information may subject me to fine, imprisonment, civil penalty, or other civil sanctions under applicable Federal laws.
50. Date (mm/dd/yyyy)
49. Attending Physician’s Signature of Attestation (Same as Item 46)
51. Physician Recertification Signature

52. Date (mm/dd/yyyy)

53. Remarks

F. OBTAIN SIGNATURE FROM PATIENT
I hereby authorize any physician, hospital, agency, or other organization to disclose any medical records or other information about my
medical condition to the Department of Health and Human Services for purposes of reviewing my application for Medicare entitlement
under the Social Security Act and/or for scientific research.
54. Signature of Patient (Signature by mark must be witnessed.)

55. Date (mm/dd/yyyy)

G. PRIVACY STATEMENT
The collection of this information is authorized by Section 226A of the Social Security Act. The information provided will be used to determine if an
individual is entitled to Medicare under the End Stage Renal Disease provisions of the law. The information will be maintained in system No. 09-70­
0520, “End Stage Renal Disease Program Management and Medical Information System (ESRD PMMIS)”, published in the Federal Register, Vol. 67, No.
116, June 17, 2002, pages 41244-41250 or as updated and republished. Collection of your Social Security number is authorized by Executive Order 9397.
Furnishing the information on this form is voluntary, but failure to do so may result in denial of Medicare benefits. Information from the ESRD PMMIS
may be given to a congressional office in response to an inquiry from the congressional office made at the request of the individual; an individual or
organization for research, demonstration, evaluation, or epidemiologic project related to the prevention of disease or disability, or the restoration
or maintenance of health. Additional disclosures may be found in the Federal Register notice cited above. You should be aware that P.L.100-503, the
Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches.
CMS-2728-U3 (03/06)
FORM CMS-2728-XX-XXX

2

LIST OF PRIMARY CAUSES OF END STAGE RENAL DISEASE
Item 15. Primary Cause of Renal Failure should be completed by the attending physician from the list below. Enter the
ICD-10-CM code to indicate the primary cause of end stage renal disease. If there are several probable causes of renal
failure, choose one as primary. Code effective as of October 2015.
ICD-10

Description

DIABETES
E13.29

Other specified diabetes mellitus with other diabetic
kidney complication

E13.22

Other specified diabetes mellitus with diabetic
chronic kidney disease

E13.21

Other specified diabetes mellitus with diabetic
nephropathy

ICD-10

Description

E09.22

Drug or chemical induced diabetes mellitus with
diabetic chronic kidney disease

E09.29

Drug or chemical induced diabetes mellitus with
other diabetic kidney complication

SECONDARY GN/VASCULITIS
D69.0

Allergic purpura

Type 2 diabetes mellitus with other diabetic kidney
complication

M30.0

Polyarteritis nodosa

M31.7

Microscopic polyangiitis

E11.21

Type 2 diabetes mellitus with diabetic nephropathy

M30.2

Juvenile polyarteritis

E11.22

Type 2 diabetes mellitus with diabetic chronic kidney
disease

M30.8

Other conditions related to polyarteritis nodosa

E10.21

Type 1 diabetes mellitus with diabetic nephropathy

M30.1

Polyarteritis with lung involvement [Churg-Strauss]

E10.22

Type 1 diabetes mellitus with diabetic chronic kidney
disease

M31.30

Wegener's granulomatosis without renal
involvement

E10.29

Type 1 diabetes mellitus with other diabetic kidney
complication

M31.31

Wegener's granulomatosis with renal involvement

M32.13

Lung involvement in systemic lupus erythematosus

M32.9

Systemic lupus erythematosus, unspecified

M32.8

Other forms of systemic lupus erythematosus

M32.19

Other organ or system involvement in systemic lupus
erythematosus

M32.14

Glomerular disease in systemic lupus erythematosus

M32.12

Pericarditis in systemic lupus erythematosus

M32.11

Endocarditis in systemic lupus erythematosus
Systemic lupus erythematosus, organ or system
involvement unspecified

E11.29

GLOMERULONEPHRITIS
N00.4

Acute nephritic syndrome with diffuse endocapillary
proliferative glomerulonephritis

N00.6

Acute nephritic syndrome with dense deposit disease

N00.7

Acute nephritic syndrome with diffuse crescentic
glomerulonephritis

N00.5

Acute nephritic syndrome with diffuse
mesangiocapillary glomerulonephritis

M32.10

N00.2

Acute nephritic syndrome with diffuse membranous
glomerulonephritis

M32.0

Drug-induced systemic lupus erythematosus

M32.15

Tubulo-interstitial nephropathy in systemic lupus
erythematosus

N00.0

Acute nephritic syndrome with minor glomerular
abnormality

M34.0

Progressive systemic sclerosis

N00.1

Acute nephritic syndrome with focal and segmental
glomerular lesions

M34.83

Systemic sclerosis with polyneuropathy

Acute nephritic syndrome with diffuse mesangial
proliferative glomerulonephritis

M34.9

Systemic sclerosis, unspecified

M34.89

Other systemic sclerosis

M34.82

Systemic sclerosis with myopathy

M34.81

Systemic sclerosis with lung involvement

Chronic nephritic syndrome with focal and
segmental glomerular lesions

M34.1

CR(E)ST syndrome

M34.2

Systemic sclerosis induced by drug and chemical

Chronic nephritic syndrome with diffuse mesangial
proliferative glomerulonephritis

D59.3

Hemolytic-uremic syndrome

M31.0

Hypersensitivity angiitis

N00.3
N03.2
N03.1
N03.3

Chronic nephritic syndrome with diffuse
membranous glomerulonephritis

N03.9

Chronic nephritic syndrome with unspecified
morphologic changes

N06.2

Isolated proteinuria with diffuse membranous
glomerulonephritis

N07.2

INTERSTITIAL NEPHRITIS/PYELONEPHRITIS
N05.9

Hereditary nephropathy, not elsewhere classified
with diffuse membranous glomerulonephritis

Unspecified nephritic syndrome with unspecified
morphologic changes

N15.9

Renal tubulo-interstitial disease, unspecified

N05.2

Unspecified nephritic syndrome with diffuse
membranous glomerulonephritis

N20.0

Calculus of kidney

N20.2

Calculus of kidney with calculus of ureter

E09.21

Drug or chemical induced diabetes mellitus with
diabetic nephropathy

N22

Calculus of urinary tract in diseases classified
elsewhere

N08

Glomerular disorders in diseases classified elsewhere

N20.9

Urinary calculus, unspecified

N16

Renal tubulo-interstitial disorders in diseases
classified elsewhere

T39.92XA

M35.04

Sicca syndrome with tubulo-interstitial nephropathy

Poisoning by unspecified nonopioid analgesic,
antipyretic and antirheumatic, intentional self-harm,
initial encounter

Form CMS-2728-XX-XXXX

3A

ICD-10

Description

ICD-10

Description

M1A.1111

Lead-induced chronic gout, right shoulder, with
tophus (tophi)

M1A.1210

Lead-induced chronic gout, right elbow, without
tophus (tophi)

M1A.1510

Lead-induced chronic gout, right hip, without
tophus (tophi)

M1A.10X0

Lead-induced chronic gout, unspecified site, without
tophus (tophi)

M1A.1110

Lead-induced chronic gout, right shoulder, without
tophus (tophi)

M1A.1120

Lead-induced chronic gout, left shoulder, without
tophus (tophi)

M1A.1121

Lead-induced chronic gout, left shoulder, with
tophus (tophi)

M1A.1191

Lead-induced chronic gout, unspecified shoulder,
with tophus (tophi)

M1A.1211

Lead-induced chronic gout, right elbow, with tophus
(tophi)

M1A.1220

Lead-induced chronic gout, left elbow, without
tophus (tophi)

M1A.1221

Lead-induced chronic gout, left elbow, with tophus
(tophi)

M1A.1290

Lead-induced chronic gout, unspecified elbow,
without tophus (tophi)

M1A.1291

Lead-induced chronic gout, unspecified elbow, with
tophus (tophi)

M1A.1311

Lead-induced chronic gout, right wrist, with tophus
(tophi)

M1A.1320

Lead-induced chronic gout, left wrist, without
tophus (tophi)

M1A.1321

Lead-induced chronic gout, left wrist, with tophus
(tophi)

M1A.1390

Lead-induced chronic gout, unspecified wrist,
without tophus (tophi)

M1A.1391

Lead-induced chronic gout, unspecified wrist, with
tophus (tophi)

M1A.1491

Lead-induced chronic gout, unspecified hand, with
tophus (tophi)

M1A.1410

Lead-induced chronic gout, right hand, without
tophus (tophi)

M1A.1411

Lead-induced chronic gout, right hand, with tophus
(tophi)

M1A.1490

Lead-induced chronic gout, unspecified hand,
without tophus (tophi)

M1A.1420

Lead-induced chronic gout, left hand, without
tophus (tophi)

M1A.10X1

Lead-induced chronic gout, unspecified site, with
tophus (tophi)

M1A.1421

Lead-induced chronic gout, left hand, with tophus
(tophi)

M1A.1310

Lead-induced chronic gout, right wrist, without
tophus (tophi)

M10.372

Gout due to renal impairment, left ankle and foot

M10.351

Gout due to renal impairment, right hip

M10.352

Gout due to renal impairment, left hip

M10.359

Gout due to renal impairment, unspecified hip

Toxic effect of lead and its compounds,
undetermined, initial encounter

M10.361

Gout due to renal impairment, right knee

M10.39

Gout due to renal impairment, multiple sites

M1A.1190

Lead-induced chronic gout, unspecified shoulder,
without tophus (tophi)

M10.362

Gout due to renal impairment, left knee

M1A.1790

Lead-induced chronic gout, unspecified ankle and
foot, without tophus (tophi)

M10.38

Gout due to renal impairment, vertebrae

M10.371

Gout due to renal impairment, right ankle and foot

INTERSTITIAL NEPHRITIS/PYELONEPHRITIS (CONT.)
T39.93XA

Poisoning by unspecified nonopioid analgesic,
antipyretic and antirheumatic, assault, initial
encounter

T39.94XA

Poisoning by unspecified nonopioid analgesic,
antipyretic and antirheumatic, undetermined, initial
encounter

T39.91XA

Poisoning by unspecified nonopioid analgesic,
antipyretic and antirheumatic, accidental
(unintentional), initial encounter

M1A.1591

Lead-induced chronic gout, unspecified hip, with
tophus (tophi)

M1A.1710

Lead-induced chronic gout, right ankle and foot,
without tophus (tophi)

M1A.1691

Lead-induced chronic gout, unspecified knee, with
tophus (tophi)

M1A.1690

Lead-induced chronic gout, unspecified knee,
without tophus (tophi)

M1A.1621

Lead-induced chronic gout, left knee, with tophus
(tophi)

M1A.1620

Lead-induced chronic gout, left knee, without
tophus (tophi)

M1A.1711

Lead-induced chronic gout, right ankle and foot,
with tophus (tophi)

M1A.1610

Lead-induced chronic gout, right knee, without
tophus (tophi)

M1A.1511

Lead-induced chronic gout, right hip, with tophus
(tophi)

M1A.1590

Lead-induced chronic gout, unspecified hip, without
tophus (tophi)

M1A.1521

Lead-induced chronic gout, left hip, with tophus
(tophi)

M1A.1520

Lead-induced chronic gout, left hip, without tophus
(tophi)

M1A.1611

Lead-induced chronic gout, right knee, with tophus
(tophi)

M1A.1720

Lead-induced chronic gout, left ankle and foot,
without tophus (tophi)

M1A.1721

Lead-induced chronic gout, left ankle and foot, with
tophus (tophi)

M1A.1791

Lead-induced chronic gout, unspecified ankle and
foot, with tophus (tophi)

M1A.18X0

Lead-induced chronic gout, vertebrae, without
tophus (tophi)

M1A.18X1

Lead-induced chronic gout, vertebrae, with tophus
(tophi)

M1A.19X0

Lead-induced chronic gout, multiple sites, without
tophus (tophi)

M1A.19X1

Lead-induced chronic gout, multiple sites, with
tophus (tophi)

T56.0X1A

Toxic effect of lead and its compounds, accidental
(unintentional), initial encounter

T56.0X2A

Toxic effect of lead and its compounds, intentional
self-harm, initial encounter

T56.0X3A
T56.0X4A

Toxic effect of lead and its compounds, assault,
initial encounter

Form CMS-2728-XX-XXXX

3B

ICD-10

Description

ICD-10

Description

INTERSTITIAL NEPHRITIS/PYELONEPHRITIS (CONT.)

HYPERTENSION/LARGE VESSEL DISEASE

M10.379

I70.1

Atherosclerosis of renal artery

I12.0

Hypertensive chronic kidney disease with stage 5
chronic kidney disease or end stage renal disease

N28.0

Ischemia and infarction of kidney

Gout due to renal impairment, unspecified ankle
and foot

M10.349

Gout due to renal impairment, unspecified hand

M10.321

Gout due to renal impairment, right elbow

M10.369

Gout due to renal impairment, unspecified knee

M10.311

Gout due to renal impairment, right shoulder

CYSTIC/HEREDITARY/CONGENITAL DISEASES

M10.329

Gout due to renal impairment, unspecified elbow

E72.04

Cystinosis

Gout due to renal impairment, unspecified site

E72.02

Hartnup's disease

M10.342

Gout due to renal impairment, left hand

E72.09

Other disorders of amino-acid transport

M10.312

Gout due to renal impairment, left shoulder

E72.00

Disorders of amino-acid transport, unspecified

M10.319

Gout due to renal impairment, unspecified shoulder

E72.01

Cystinuria

M10.322

Gout due to renal impairment, left elbow

E72.52

Trimethylaminuria

M10.331

Gout due to renal impairment, right wrist

E72.53

Hyperoxaluria

M10.332

Gout due to renal impairment, left wrist

E74.4

M10.339

Gout due to renal impairment, unspecified wrist

Disorders of pyruvate metabolism and
gluconeogenesis

M10.341

Gout due to renal impairment, right hand

E74.8

E20.1

Pseudohypoparathyroidism

Other specified disorders of carbohydrate
metabolism

E83.59

Other disorders of calcium metabolism

E77.1

Defects in glycoprotein degradation

N00.8

Acute nephritic syndrome with other morphologic
changes

E75.249

Niemann-Pick disease, unspecified

E77.9

Disorder of glycoprotein metabolism, unspecified

E77.8

Other disorders of glycoprotein metabolism

E75.3

Sphingolipidosis, unspecified

E75.248

Other Niemann-Pick disease
Niemann-Pick disease type C

M10.30

N14.3

Nephropathy induced by heavy metals

N15.8

Other specified renal tubulo-interstitial diseases

N14.4

Toxic nephropathy, not elsewhere classified

N14.2

Nephropathy induced by unspecified drug,
medicament or biological substance

E75.242
E75.241

Niemann-Pick disease type B

N14.1

Nephropathy induced by other drugs, medicaments
and biological substances

E75.240

Niemann-Pick disease type A

E75.22

Gaucher disease

N14.0

Analgesic nephropathy

E75.21

Fabry (-Anderson) disease

N07.8

Hereditary nephropathy, not elsewhere classified
with other morphologic lesions

E75.243

Niemann-Pick disease type D

E77.0

Defects in post-translational modification of
lysosomal enzymes

N06.9

Isolated proteinuria with unspecified morphologic
lesion

N07.9

Hereditary nephropathy, not elsewhere classified
with unspecified morphologic lesions

Q60.0

Renal agenesis, unilateral

Q60.1

Renal agenesis, bilateral

Q60.2

Renal agenesis, unspecified

Q60.3

Renal hypoplasia, unilateral

Q60.4

Renal hypoplasia, bilateral

N07.7

Hereditary nephropathy, not elsewhere classified
with diffuse crescentic glomerulonephritis

N07.6

Hereditary nephropathy, not elsewhere classified
with dense deposit disease

N07.1

Hereditary nephropathy, not elsewhere classified
with focal and segmental glomerular lesions

N05.7

Unspecified nephritic syndrome with diffuse
crescentic glomerulonephritis

N15.0

Balkan nephropathy

N05.0

Unspecified nephritic syndrome with minor
glomerular abnormality

N07.0

Hereditary nephropathy, not elsewhere classified
with minor glomerular abnormality

Q60.5

Renal hypoplasia, unspecified

Q60.6

Potter's syndrome

Unspecified nephritic syndrome with dense deposit
disease

Q63.9

Congenital malformation of kidney, unspecified

Unspecified nephritic syndrome with other
morphologic changes

Q63.0

Accessory kidney

Q63.1

Lobulated, fused and horseshoe kidney

Q63.2

Ectopic kidney

Q63.3

Hyperplastic and giant kidney

N05.6
N05.8
N06.0

Isolated proteinuria with minor glomerular
abnormality

N06.1

Isolated proteinuria with focal and segmental
glomerular lesions

Q63.8

Other specified congenital malformations of kidney

Q85.1

Tuberous sclerosis

N06.6

Isolated proteinuria with dense deposit disease

Q61.2

Polycystic kidney, adult type

N06.7

Isolated proteinuria with diffuse crescentic
glomerulonephritis

Q61.19

Other polycystic kidney, infantile type

N06.8

Isolated proteinuria with other morphologic lesion

Q61.11

Cystic dilatation of collecting ducts

N05.1

Unspecified nephritic syndrome with focal and
segmental glomerular lesions

Q61.5

Medullary cystic kidney

Q62.11

Congenital occlusion of ureteropelvic junction

Q62.12

Congenital occlusion of ureterovesical orifice

Form CMS-2728-XX-XXXX

3C

ICD-10

Description

CYSTIC/HEREDITARY/CONGENITAL DISEASES (CONT.)

ICD-10

Description

C82.50

Diffuse follicle center lymphoma, unspecified site

C85.19

Unspecified B-cell lymphoma, extranodal and solid
organ sites

Q62.2

Congenital megaureter

Q62.0

Congenital hydronephrosis

C90.00

Multiple myeloma not having achieved remission

Q62.10

Congenital occlusion of ureter, unspecified

T86.93

Unspecified transplanted organ and tissue infection

Q79.4

Prune belly syndrome

T86.99

Q79.51

Congenital hernia of bladder

Other complications of unspecified transplanted
organ and tissue

Q87.5

Other congenital malformation syndromes with
other skeletal changes

T86.91

Unspecified transplanted organ and tissue rejection

T86.90

Q87.3

Congenital malformation syndromes involving early
overgrowth

Unspecified complication of unspecified
transplanted organ and tissue

T86.92

Unspecified transplanted organ and tissue failure

Q89.8

Other specified congenital malformations

T86.11

Kidney transplant rejection

Q87.89

Other specified congenital malformation syndromes,
not elsewhere classified

T86.12

Kidney transplant failure

T86.13

Kidney transplant infection

E78.71

Barth syndrome

T86.19

Other complication of kidney transplant

Q87.2

Congenital malformation syndromes predominantly
involving limbs

T86.10

Unspecified complication of kidney transplant

T86.40

Unspecified complication of liver transplant

T86.49

Other complications of liver transplant

T86.43

Liver transplant infection

T86.41

Liver transplant rejection

T86.42

Liver transplant failure

T86.30

Unspecified complication of heart-lung transplant

T86.20

Unspecified complication of heart transplant

T86.33

Heart-lung transplant infection

E78.72

Smith-Lemli-Opitz syndrome

Q87.81

Alport syndrome

NEOPLASMS/TUMORS
C64.1

Malignant neoplasm of right kidney, except renal
pelvis

C64.2

Malignant neoplasm of left kidney, except renal
pelvis

C64.9

Malignant neoplasm of unspecified kidney, except
renal pelvis

T86.39

Other complications of heart-lung transplant

T86.32

Heart-lung transplant failure

C68.9

Malignant neoplasm of urinary organ, unspecified

T86.31

Heart-lung transplant rejection

D30.00

Benign neoplasm of unspecified kidney

T86.290

Cardiac allograft vasculopathy

D30.01

Benign neoplasm of right kidney

T86.23

Heart transplant infection

D30.02

Benign neoplasm of left kidney

T86.21

Heart transplant rejection

D30.9

Benign neoplasm of urinary organ, unspecified

T86.22

Heart transplant failure

E85.9

Amyloidosis, unspecified

T86.298

Other complications of heart transplant

C84.Z9

Other mature T/NK-cell lymphomas, extranodal and
solid organ sites

T86.812

Lung transplant infection

T86.818

Other complications of lung transplant

T86.811

Lung transplant failure

T86.810

Lung transplant rejection

T86.819

Unspecified complication of lung transplant

T86.00

Unspecified complication of bone marrow transplant

Other specified types of non-Hodgkin lymphoma,
extranodal and solid organ sites

T86.01

Bone marrow transplant rejection

T86.02

Bone marrow transplant failure

C85.80

Other specified types of non-Hodgkin lymphoma,
unspecified site

T86.03

Bone marrow transplant infection

C85.29

Mediastinal (thymic) large B-cell lymphoma,
extranodal and solid organ sites

T86.09

Other complications of bone marrow transplant

T86.850

Intestine transplant rejection

T86.851

Intestine transplant failure

T86.852

Intestine transplant infection

T86.858

Other complications of intestine transplant
Unspecified complication of intestine transplant

C86.4

Blastic NK-cell lymphoma

C85.99

Non-Hodgkin lymphoma, unspecified, extranodal
and solid organ sites

C85.90
C85.89

C85.20

Non-Hodgkin lymphoma, unspecified, unspecified
site

Mediastinal (thymic) large B-cell lymphoma,
unspecified site

C85.10

Unspecified B-cell lymphoma, unspecified site

C84.Z0

Other mature T/NK-cell lymphomas, unspecified site

T86.859

C84.A9

Cutaneous T-cell lymphoma, unspecified, extranodal
and solid organ sites

T86.831

Bone graft failure

T86.898

Other complications of other transplanted tissue

C84.A0

Cutaneous T-cell lymphoma, unspecified, unspecified
site

T86.892

Other transplanted tissue infection

T86.891

Other transplanted tissue failure

C84.99

Mature T/NK-cell lymphomas, unspecified,
extranodal and solid organ sites

T86.890

Other transplanted tissue rejection

C84.90

Mature T/NK-cell lymphomas, unspecified,
unspecified site

T86.849

Unspecified complication of corneal transplant

T86.848

Other complications of corneal transplant

T86.839

Unspecified complication of bone graft

T86.832

Bone graft infection

C82.59

Diffuse follicle center lymphoma, extranodal and
solid organ sites

Form CMS-2728-XX-XXXX

3D

ICD-10

Description

NEOPLASMS/TUMORS (CONT.)
T86.830

Bone graft rejection

T86.899

Unspecified complication of other transplanted
tissue

T86.838

Other complications of bone graft

MISCELLANEOUS CONDITIONS
B20

Human immunodeficiency virus [HIV] disease

K76.7

Hepatorenal syndrome

N17.1

Acute kidney failure with acute cortical necrosis

R69

Illness, unspecified

R99

Ill-defined and unknown cause of mortality

D57.1

Sickle-cell disease without crisis

D57.811

Other sickle-cell disorders with acute chest syndrome

D57.812

Other sickle-cell disorders with splenic sequestration

D57.819

Other sickle-cell disorders with crisis, unspecified

N28.82

Megaloureter

N28.89

Other specified disorders of kidney and ureter

O12.10

Gestational proteinuria, unspecified trimester

O12.20

Gestational edema with proteinuria, unspecified
trimester

O26.839

Pregnancy related renal disease, unspecified
trimester

Form CMS-2728-XX-XXXX

3E

INSTRUCTIONS FOR COMPLETION OF END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
For whom should this form be completed:
This form SHOULD NOT be completed for those patients who
are in acute renal failure. Acute renal failure is a condition in
which kidney function can be expected to recover after a
short period of dialysis, i.e., several weeks or months.
This form MUST BE completed within 45 days for ALL
patients beginning any of the following:
Check the appropriate block that identifies the reason for
submission of this form.

Initial
For all patients who initially receive a kidney transplant
instead of a course of dialysis. For patients for whom a
regular course of dialysis has been prescribed by a physician
because they have reached that stage of renal impairment
that a kidney transplant or regular course of dialysis is
necessary to maintain life. The first date of a regular course
of dialysis is the date this prescription is implemented
whether as an inpatient of a hospital, an outpatient in a
dialysis

center or facility, or a home patient. The form should be
completed for all patients in this category even if the patient
dies within this time period.

Re-entitlement
For beneficiaries who have already been entitled to ESRD
Medicare benefits and those benefits were terminated
because their coverage stopped 3 years post transplant but
now are again applying for Medicare ESRD benefits because
they returned to dialysis or received another kidney
transplant.
For beneficiaries who stopped dialysis for more than 12
months, have had their Medicare ESRD benefits terminated
and now returned to dialysis or received a kidney transplant.
These patients will be reapplying for Medicare ESRD benefits.

Supplemental
Patient has received a transplant or trained for self-care
dialysis within the first 3 months of the first date of dialysis
and initial form was submitted.

All items except as follows: To be completed by the attending physician, head nurse, or social worker involved in this patient’s
treatment of renal disease.
Items 15, 17-18, 26-27, 49-50: To be completed by the attending physician.
Item 44: To be signed by the attending physician or the physician familiar with the patient’s self-care dialysis training.
Items 54 and 55: To be signed and dated by the patient.
1.

Enter the patient’s legal name (Last, first, middle initial).
Name should appear exactly the same as it appears on
patient’s social security or Medicare card.

2.

If the patient is covered by Medicare, enter his/her Medicare
claim number as it appears on his/her Medicare card.

3.

Enter the patient’s own social security number. This number
can be verified from his/her social security card.

4.

Enter patient’s date of birth (2-digit Month, Day, and 4-digit
Year). Example 07/25/1950.

5.

Enter the patient’s mailing address (number and street or
post office box number, city, state, and ZIP code.)

6.

Enter the patient’s home area code and telephone number.

7.

Check the appropriate block to identify sex.

8.

Check the appropriate block to identify ethnicity. Definitions
of the ethnicity categories for Federal statistics are as follows:
Not Hispanic or Latino—A person of culture or origin not
described below, regardless of race.
Hispanic or Latino—A person of Cuban, Puerto Rican, or
Mexican culture or origin regardless of race. Please complete
Item 9 and provide the country, area of origin, or ancestry to
which the patient claims to belong.

9.

Country/Area of origin or ancestry—Complete if information
is available or if directed to do so in question 8.

10.

Check the appropriate block(s) to identify race. Definitions of
the racial categories for Federal statistics are as follows:
White—A person having origins in any of the original white
peoples of Europe, the Middle East or North Africa.
Black or African American—A person having origins in any
of the black racial groups of Africa. This includes native-born
Black Americans, Africans, Haitians and residents of nonSpanish speaking Caribbean Islands of African descent.
American Indian/Alaska Native—A person having origins in
any of the original peoples of North America and South
America (including Central America) and who maintains
tribal affiliation or community attachment. Print the name of
the enrolled or principal tribe to which the patient claims to
be a member.
Asian—A person having origins in any of the original peoples
of the Far East, Southeast Asia or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand and
Vietnam.
Native Hawaiian or Other Pacific Islander—A person
having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands. Please complete Item 9
and provide the country, area of origin, or ancestry to which
the patient claims to belong.

DISTRIBUTION OF COPIES:
•
•
•

Forward the first part (blue) of this form to the Social Security office servicing the claim.
Forward the second part (green) of this form to the ESRD Network Organizations.
Retain the last part (white) in the patient’s medical records file.

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 is 0938-0046. The time required to complete this information collection estimated to average 45 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, Attention: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Please do not send applications,
claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact 1-800-MEDICARE.

Form CMS-2728-XX-XXXX

4

11.

Check the appropriate yes or no block to indicate if patient is
applying for ESRD Medicare. Note: Even though a person
may already be entitled to general Medicare coverage,
he/she should reapply for ESRD Medicare coverage.

12.

Check all the blocks that apply to this patient’s current
medical insurance status.
Medicaid—Patient is currently receiving State Medicaid
benefits.
Medicare—Patient is currently entitled to Federal Medicare
benefits.
Employer Group Health Insurance—Patient receives medical
benefits through an employee health plan that covers
employees, former employees, or the families of employees o
former employees.
DVA—Patient is receiving medical care from a Department of
Veterans Affairs facility.
Medicare Advantage—Patient is receiving medical benefits
under a Medicare Advantage organization.
Other Medical Insurance—Patient is receiving medical
benefits under a health insurance plan that is not Medicare,
Medicaid, Department of Veterans Affairs, HMO/M+C
organization, nor an employer group health insurance plan.
Examples of other medical insurance are Railroad Retirement
and CHAMPUS beneficiaries.
None—Patient has no medical insurance plan.

13.

14.

Enter the patient’s most recent recorded height in inches OR
centimeters at time form is being completed. If entering
height in centimeters, round to the nearest centimeter.
Estimate or use last known height for those unable to be
measured. (Example of inches - 62. DO NOT PUT 5’2”) NOTE:
For amputee patients, enter height prior to amputation.

19a1.

Enter the serum albumin value (g/dl) and date test was taken.
This value and date must be within 45 days prior to first
dialysis treatment or kidney transplant.

19a2.

Enter the lower limit of the normal range for serum albumin
from the laboratory which performed the serum albumin test
entered in 19a1.

19a3.

Enter the serum albumin lab method used (BCG or BCP).

19b.

Enter the serum creatinine value (mg/dl) and date test was
taken. THIS FIELD MUST BE COMPLETED. Value must be
within 45 days prior to first dialysis treatment or kidney
transplant.

19c.

Enter the hemoglobin value (g/dl) and date test was taken.
This value and date must be within 45 days prior to the first
dialysis treatment or kidney transplant.

19d.

Enter the HbA1c value and the date the test was taken. The
date must be within 1 year prior to the first dialysis
treatment or kidney transplant.

19e.

Enter the Lipid Profile values and date test was taken. These
values: TC–Total Cholesterol; LDL–LDL Cholesterol; HDL–HDL
Cholesterol; TG–Triglycerides, and date must be within 1 year
prior to the first dialysis treatment or kidney transplant.

20.

Enter the name of the dialysis facility where patient is
currently receiving care and who is completing this form for
patient.

21.

Enter the 6-digit Medicare identification code of the dialysis
facility in item 20.

22.

If the person is receiving a regular course of dialysis
treatment, check the appropriate anticipated long-term
treatment setting at the time this form is being completed.

23.

If the patient is, or was, on regular dialysis, check the
anticipated long-term primary type of dialysis:
Hemodialysis, (enter the number of sessions prescribed per
week and the hours that were prescribed for each session),
CAPD (Continuous Ambulatory Peritoneal Dialysis) and CCPD
(Continuous Cycling Peritoneal Dialysis), or Other. Check only
one block. NOTE: Other has been placed on this form to be
used only to report IPD (Intermittent Peritoneal Dialysis) and
any new method of dialysis that may be developed prior to
the renewal of this form by Office of Management and
Budget.

24.

Enter the date (month, day, year) that a “regular course of
chronic dialysis” began. The beginning of the course of
dialysis is counted from the beginning of regularly scheduled
dialysis necessary for the treatment of end stage renal
disease (ESRD) regardless of the dialysis setting. The date of
the first dialysis treatment after the physician has determined
that this patient has ESRD and has written a prescription for
a “regular course of dialysis” is the “Date Regular Chronic
Dialysis Began” regardless of whether this prescription was
implemented in a hospital/ inpatient, outpatient, or home
setting and regardless of any acute treatments received prior
to the implementation of the prescription.

Enter the patient’s most recent recorded dry weight in
pounds OR kilograms at time form is being completed. If
entering weight in kilograms, round to the nearest kilogram.

NOTE: For amputee patients, enter actual dry weight.
15.

To be completed by the attending physician. Enter the
ICD10-CM from back of form to indicate the primary cause of
end stage renal disease. These are the only acceptable causes
of end stage renal disease.

16.

Check the first box to indicate employment status 6 months
prior to renal failure and the second box to indicate current
employment status. Check only one box for each time
period. If patient is under 6 years of age, leave blank.

17.

To be completed by the attending physician. Check all comorbid conditions that apply.
*Cerebrovascular Disease includes history of
stroke/cerebrovascular accident (CVA) and transient ischemic
attack (TIA).
*Peripheral Vascular Disease includes absent foot pulses,
prior typical claudication, amputations for vascular disease,
gangrene and aortic aneurysm.
*Drug dependence means dependent on illicit drugs.

18.

Prior to ESRD therapy, check the appropriate box to indicate
whether the patient received Exogenous erythropoetin (EPO)
or equivalent, was under the care of a nephrologist and/or
was under the care of a kidney dietitian. Provide vascular
access information as to the type of access used (ArterioVenous Fistula (AVF), graft, catheter (including port device)
or other type of access) when the patient first received
outpatient dialysis. If an AVF access was not used, was a
maturing AVF or graft present?

NOTE: For those patients re-entering the Medicare program after
benefits were terminated, Items 19a thru 19c should contain
initial laboratory values within 45 days prior to the most recent
ESRD episode. Lipid profiles and HbA1c should be within 1 year
of the most recent ESRD episode. Some tests may not be required
for patients under 21 years of age.
Form CMS-2728-XX-XXXX

NOTE: For these purposes, end stage renal disease means
irreversible damage to a person’s kidneys so severely affecting
his/her ability to remove or adjust blood wastes that in order to
maintain life he or she must have either a course of dialysis or a
kidney transplant to maintain life.
If re-entering the Medicare program, enter beginning date of the
current ESRD episode. Note in Remarks, Item 53, that patient is
restarting dialysis.
25.

Enter date patient started chronic dialysis at current facility
of dialysis services. In cases where patient transferred to
current dialysis facility, this date will be after the date in Item
24.

26.

Enter whether the patient has been informed of their
options for receiving a kidney transplant.

27.

If the patient has not been informed of their options
(answered “no” to Item 26), then enter all reasons why a
5

kidney transplant was not an option for this patient at this
time.

patient’s renal treatment at the time this form is completed.
47.

Enter the area code and telephone number of the physician
who is supervising the patient’s renal treatment at the time
this form is completed.

48.

Enter the physician’s UPIN assigned by CMS.

28.

Enter the date(s) of the patient’s kidney transplant(s). If
reentering the Medicare program, enter current transplant
date.

29.

Enter the name of the hospital where the patient received a
kidney transplant on the date in Item 28.

30.

Enter the 6-digit Medicare identification code of the hospital
in Item 29 where the patient received a kidney transplant on
the date entered in Item 28.

31.

Enter date patient was admitted as an inpatient to a hospital
in preparation for, or anticipation of, a kidney transplant
prior to the date of the actual transplantation. This includes
hospitalization for transplant workup in order to place the
patient on a transplant waiting list.

32.

Enter the name of the hospital where patient was admitted
as an inpatient in preparation for, or anticipation of, a
kidney transplant prior to the date of the actual
transplantation.

49.

Enter the 6-digit Medicare identification number for hospital
in Item 32.

To be signed by the physician supervising the patient’s kidney
treatment. Signature of physician identified in Item 46. A
stamped signature is unacceptable.

50.

Enter date physician signed this form.

51.

To be signed by the physician who is currently following the
patient. If the patient had decided initially not to file an
application for Medicare, the physician will be re-certifying
that the patient is end stage renal, based on the same
medical evidence, by signing the copy of the CMS-2728 that
was originally submitted and returned to the provider. If you
do not have a copy of the original CMS-2728 on file,
complete a new form.

52.

The date physician re-certified and signed the form.

53.

This remarks section may be used for any necessary
comments by either the physician, patient, ESRD Network or
social security field office.

54.

The patient’s signature authorizing the release of
information to the Department of Health and Human
Services must be secured here. If the patient is unable to
sign the form, it should be signed by a relative, a person
assuming responsibility for the patient or by a survivor.

55.

The date patient signed form.

33.
34.

Check the appropriate functioning or non-functioning block.

35.

Enter the type of kidney transplant organ donor, Deceased,
Living Related or Living Unrelated, that was provided to the
patient.

36.

If transplant is nonfunctioning, enter date patient returned
to a regular course of dialysis. If patient did not stop dialysis
post transplant, enter transplant date.

37.

If applicable, check where patient is receiving dialysis
treatment following transplant rejection. A nursing home or
skilled nursing facility is considered as home setting

Self-dialysis Training Patients (Medicare Applicants
Only)
Normally, Medicare entitlement begins with the third month
after the month a patient begins a regular course of dialysis
treatment. This 3-month qualifying period may be waived if a
patient begins a self-dialysis training program in a Medicare
approved training facility and is expected to self-dialyze
after the completion of the training program. Please
complete items 38-43 if the patient has entered into a selfdialysis training program. Items 38-43 must be completed if
the patient is applying for a Medicare waiver of the 3-month
qualifying period for dialysis benefits based on participation
in a self-care dialysis training program.
38.

Enter the name of the provider furnishing self-care dialysis
training.

39.

Enter the 6-digit Medicare identification number for the
training provider in Item 38.

40.

Enter the date self-dialysis training began.

41.

Check the appropriate block which describes the type of
selfcare dialysis training the patient began. If the patient
trained for hemodialysis, enter whether the training was to
perform dialysis in the home setting or in the facility (in
center). If the patient trained for IPD (Intermittent Peritoneal
Dialysis), report as Other.

42.

Check the appropriate block as to whether or not the
physician certifies that the patient is expected to complete
the training successfully and self-dialyze on a regular basis.

43.

Enter date patient completed or is expected to complete
selfdialysis training.

44.

Enter printed name and signature of the attending physician
or the physician familiar with the patient’s self-care dialysis
training.

45.

Enter the Unique Physician Identification Number (UPIN) of
physician in Item 44. (See Item 48 for explanation of UPIN.)

46.

Enter the name of the physician who is supervising the

Form CMS-2728-XX-XXXX

A system of physician identifiers is mandated by Section 9202
of the Consolidated Omnibus Budget Reconciliation Act of
1985. It requires a unique identifier for each physician who
provides services for which Medicare payment is made. An
identifier is assigned to each physician regardless of his or her
practice configuration. The UPIN is established in a national
Registry of Medicare Physician Identification and Eligibility
Records (MPIER). Transamerica Occidental Life Insurance
Company is the Registry Carrier that establishes and
maintains the national registry of physicians receiving Part
Medicare payment. Its address is: UPIN Registry, Transamerica
Occidental Life, P.O. Box 2575, Los Angeles, CA 90051-0575.

6