ESRD Claims Processing - Medical Evidence Report

The Social Security Administration (SSA) Office that services the claim will receive the completed Form CMS-2728-U3 "End Stage Renal Disease (ESRD) Medical Evidence Report - Medicare Entitlement and/or Patient Registration." Contact the local Social Security Administration (SSA) Office for copies of the form. Facilities also submit copies of and are responsible for verifying the information on the form and resolving any questionable items before sending the information to the ESRD Networks who transmit the information to CMS.

Facilities must submit the Medical Evidence Report within 45 days after either a transplant or the start of a regular course of dialysis (whichever occurs first). A copy of the completed form is maintained with the patients' medical records to support billing.

Noridian will use the dates sent from CMS to process renal dialysis claims. The Form CMS-2728-U3 contains important data elements; date of dialysis, date of transplant and restart dates which impact reimbursement and quality improvement measures. Facilities should review the patient Medicare claims, the form and chart information for internal audits or quality measures.

Primary Cause of Renal Failure

  • Item 15: To be completed by the attending physician. Enter the ICD-10-CM to indicate the primary cause of end stage renal disease. If there are several, choose one as primary.

ESRD Patients in Dialysis Treatment - Initial Date

  • Item 24: Enter the date of the first regular course of dialysis treatment after the physician's order. The first date of treatment may be in the inpatient of a hospital, outpatient dialysis center or home setting.

Note: If re-entering the Medicare program, enter beginning date of the current ESRD episode. Note in Remarks, Item 53, that patient is restarting dialysis. This section may be used for any necessary comment by either the physician, patient, ESRD Network or the SSA.

  • Item 25: Enter the date the patient started chronic dialysis at the current facility.  In cases where the patient transferred to the current dialysis facility, this date will be after the date in Item 24.

Kidney Transplant Patients

  • Item 28: Enter the date(s) of the patient's kidney transplant(s). If reentering the Medicare program, enter current transplant date.
  • Item 31: Enter the 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. This includes hospitalization for transplant workup to place the patient on a transplant waiting list.

Self-dialysis Training Patients

  • Item 40: Enter the date self-dialysis training began.
  • Item 43: Enter date patient completed or is expected to complete self-dialysis training.
  • Items 38-43: These items 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.

Resources

 

Last Updated Oct 31 , 2022