End Stage Renal Disease (ESRD) / Dialysis Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

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Brief Description
History and Physical reports (include medical history and current list of medications)
Practitioner, nurse, and ancillary progress note
Dialysis treatment sheets
Proof of phone calls
Treating practitioner's written order
Vital sign records, weight sheets, care plans, treatment records
CMS 2728 (End stage renal disease medical evidence report; Medicare entitlement and/or beneficiary registration)
Beneficiary name and date of service on all documentation
Documentation as required in LCD or NCD
Any additional documentation to support the reasonable necessity of the service(s) performed
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Signature attestation and credentials of all personnel providing services
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received.

View the End Stage Renal Disease (ESRD) webpage for additional information and resources.

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Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.