CMS-2744 B ESRD Medical Information System ESRD Facility Survey

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

END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (TRANSPLANT CENTER ONLY)
For Survey Period

Kidney Transplants Performed — TO BE COMPLETED BY KIDNEY TRANSPLANT CENTERS ONLY
Patients Transplanted and Donor Type
Patient who Received
Transplant at this at this
Facility

Eligibility Status of Patients Transplanted at
this Facility During the Survey Period

42

Currently
enrolled
in Medicare

Medicare
application
pending

43

44

Non-Medicare
United States
Resident

Other

45

46

Patients Awaiting
Transplant

Transplant Procedures Performed at This Facility
Deceased
Donor

Living
Related
Donor

Living
Unrelated
Donor

Multi-Organ

PairedExchange

Total
Fields 47 – 51

47

48

49

50

51

52

Dialysis

Non-Dialysis

53

54

Remarks and Comments

Completed by (Name)

Date

Title

Phone number

REMARKS REGARDING INFORMATION PROVIDED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAGE OF THE SURVEY
This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as
provided for in the Privacy Act of 1974 (5 USC 5520; 45 CFR, Part 5a). 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-XXXX (Expires XX/XX/XXXX). This is a mandatory information collection. The time required to complete this
information collection is estimated to average two (2) hours 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 comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** 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 Christina Goatee.
Form CMS-2744B (XX/XX)

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KIDNEY TRANSPLANTS PERFORMED
(FOR COMPLETION BY KIDNEY TRANSPLANT CENTERS ONLY)
Note: Every kidney transplant must be reported in this category, even if the transplant never functioned.

Patients/transplants
• Field 42: Patients Who Received Transplant at This Facility. Enter the number of patients who received a kidney
transplant at your facility, during the survey period. If a patient received more than one transplant at your
center during the survey period, the patient is to be counted only once. Total of fields 43 + 44 + 45 + 46.
Patient Eligibility Status of Patients Transplanted During Survey Period
Note: Fields 43 through 46 refer to those patients actually transplanted during the survey period. Ensure that the
total of fields 43 through 46 equals the count in field 42.
• Fields 46 and 47 (Non-Medicare U.S. Residents and Other) refers to foreign nationals. A foreign national is any
person who is not a U.S. citizen, and includes permanent resident aliens.
• Field 43: Currently Enrolled in Medicare. Enter the number of patients transplanted during the survey period
who were enrolled in Medicare, at the time of transplant. Count Medicare transplant recipients based on
enrollment rather than primary insurer.
• Field 44: Medicare Application Pending. Enter the number of patients transplanted during the survey period that
had Medicare applications pending, at the time of transplant.
• Field 45: Non-Medicare, U.S. Residents. Enter the number of patients transplanted during the survey period
who, at the time of transplant, were not enrolled in Medicare and did not have Medicare applications pending,
who were either U.S. citizens or a foreign national U.S. resident.
• Field 46: Non-Medicare, Other. Enter the number of patients transplanted during the survey period who, at
the time of transplant, were not enrolled in Medicare, did not have Medicare applications pending, and were
neither a U.S. citizen nor a U.S. resident (e.g., foreign national).
Transplants Performed at This Facility
• Field 47: Transplants Performed at This Facility-Deceased Donor. Enter the number of deceased donor kidney
transplants performed at your center, as of the last day of the survey period.
• Field 48: Transplants Performed at This Facility-Living Related Donor. Enter the number of living related donor
kidney transplants performed at your center, as of the last day of the survey period.
• Field 49: Transplants Performed at This Facility-Living Unrelated Donor. Enter the number of living unrelated
donor kidney transplants performed at your center, as of the last day of the survey period.
• Field 50: Transplants Performed at This Facility-Multi-Organ. Enter the number of multi-organ kidney transplants
performed at your center (i.e. kidney-pancreas), as of the last day of the survey period.
• Field 51: Transplants Performed at This Facility-Paired Exchange. Enter the number of paired-exchange living
donor kidney transplants performed at your center, as of the last day of the survey period.
• Field 52: Transplants Performed at This Facility-Total Fields 47, 48, 49, 50, and 51. Enter the sum of fields 47 + 48
+ 49 + 50 + 51.
Patients Awaiting Transplant:
• Field 53: Patients Awaiting Transplant—Dialysis. Enter the number of dialysis patients actively awaiting a kidney
transplant at your center, as of the last day of the survey period. These patients must (a) be medically able, (b)
have given consent, and (c) be on an active transplant list. This count is limited to individuals awaiting transplant
at the reporting center.
• Field 54: Patients Awaiting Transplant—Non-Dialysis. Following the criteria described above, enter the number
of non-dialysis patients who were awaiting transplant, as of the last day of the survey period. This is to include
patients scheduled for transplant who had not yet initiated a regular course of dialysis.

Remarks and Comments
You may include here any remarks or additional information you wish to supply concerning the information
furnished on this survey.

Signatures Part Two of the Facility Survey requires signatures as follows:
Completed by: Enter the date completed and the name, title and telephone number of the person who completed
the Facility Survey for your facility.
Instructions: Form CMS-2744B (XX/XX)

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