2728 Frequently Asked Questions:

 

 

Q:  When is the 2728 form due?

A:  Within 45 days of the date they started at your facility. 

 

Q:  How long do we need to keep a copy of the 2728 form? 

A:  This is up to your individual facility policy.  At Network 16, we keep all 2728 forms for 2 years after the patient’s date of death.

 

Q:  I need more 2728 forms.  How can I get more?

A:  You can request them from your local social security office.  Please check to make sure you have received the most current version.  (Check the bottom left corner – it should read:  Form CMS-2728-U3 (06/04) Ef (03/2005)).

 

Q:  If the patient already has Medicare, do I need to submit a form?

A:  Yes.  The ESRD Medical Evidence Report serves as both a Medicare entitlement form and as a registry for new ESRD patients. 

 

 

Form Type:  Initial

 

Q:  The patient is Hispanic or Latino.  Do I need to fill in a race in field 10?

A:  Yes – please fill in the race the patient most associates himself or herself with.  If unknown, please indicate white.

 

Q:  The form says I have to fill in a Country/Area of origin (the patient is Hispanic or Latino / Native Hawaiian or Other Pacific Islander).  What do I put for country or area of origin in field 9? 

A:  Please put whatever country the patient most associates himself or herself with.

 

Q:  The patient is multi-racial.  What do I check on the form?

A:  You can check more than one race on the 2728 form.  Please mark all that apply.

 

Q:  Field 11:  The patient already has Medicare.  Do I always mark this field (Is Patient Applying for ESRD Medical Coverage?) as “No” for these patients?

A:  No.  ESRD Medical Coverage is a special program with different rules for when the coverage begins and when it ends.  If a patient has Medical Coverage from Medicare, this does not mean they have ESRD Medical Coverage and may wish to apply for it.

 

Q:  The patient fits multiple prior and current employment statuses.  Can I check more than one?

A:  You can only choose one status per category (prior/current).

 

Q:  In field 18a-c, how do you indicate a timeframe of less than 6 months?

A:  This field was unintentionally left off of the 2728 form.  If the timeframe for any of these questions is less than 6 months, please write < 6 mos. on the same line.

 

Q:  In field 18d, the nephrologist marked that a graft was the access used on the first outpatient dialysis.  Why do I need to mark the follow up questions?

A:  If a patient has a graft as the access used on the first outpatient dialysis, please answer the 1st follow-up question – is maturing AVF present.  The patient may have a fistula that is failing to mature and a graft may be placed instead of a catheter in this case.  A graft may also be placed as they wait for a fistula to mature. 

 

Q:  Field 19d-e:  I don’t have an HbA1c or Lipid Profiles for the patient.  Can I submit the form?

A:  Yes.  Although the Network would like you to report as many labs as possible, Serum Creatinine is the only required lab for the 2728 form.

 

Q:  Field 24:  What date to I use as the date regular chronic dialysis began?

A:  Field 24 is for the patient’s first chronic dialysis ever as determined by the nephrologist.  This could be the first time the patient dialyzed at your facility or it could be an inpatient date.  Please see the instructions attached to the 2728 form for further detail.

 

Q:  I have included training on the form.  Where does the nephrologist sign?

A:  If the nephrologist is the attesting physician and the physician familiar with the patient’s training, he or she will sign and date in field #44 and in fields 49/50.  If the attesting physician is different from the physician familiar with the patient’s training, you will need signatures from both nephrologists in the appropriate sections.

 

Q:  Do I use the NPI or UPIN in field 48? 

A:  If the signing nephrologist has both an NPI and a UPIN, please fill in the UPIN in this field.  If the signing nephrologist only has an NPI, please fill in the NPI in this field.

 

Q:  What is field 51 – Physician Recertification signature?

A:  This is for SSA purposes only.  It is not used for Network purposes.

 

Q:  The patient died before signing the 2728 form.  How do I handle this?

A:  Please submit the form with the date of death written in the remarks section (field 53) along with a comment indicating the patient expired before they were able to sign the 2728.  Please leave the patient signature and date fields (Fields 54/55) blank.

 

Q:  The patient stopped dialysis but has not died (ex. Pt discontinued, Regained Function or is Lost to Follow-Up).  Can I submit the form without a signature for field 54?

A:  No.  You must get a signature from either the patient, a family member or spouse of the patient or a POA.  The Network cannot accept forms without a signature in field 54 (unless the patient has died).

 

 

Form Type:  Re-Entitlement

 

Q:  If a patient had a prior kidney transplant but has never been on dialysis before, what type of 2728 do I check?

A:  The type of 2728 form for a patient returning after kidney transplant failure is a Re-entitlement 2728.

 

Q:  If a patient has Medicare already and is returning after a failed transplant, do I need to submit a Re-entitlement 2728?

A:  Submit a Re-entitlement 2728 for all patients returning after a failed transplant if it has been greater than 3 years since the transplant regardless of their Medicare status.

 

 

Form Type:  Supplemental

 

Q:  Who do I submit a supplemental form for?

A:  Patients who started as InCenter Hemodialysis but started PD or Home Hemodialysis training within 3 months of their start date, or had a transplant within 3 months of their start date.

 

Q:  Do you do a supplemental form for patients who started within 90 days or do you count by 3 months?

A:   You would count by 3 months.  Ex. – A patient started InCenter Hemodialysis on Jan 15th and started CAPD training March 20th needs a supplemental form for their training.  This patient does not need a form if they start training on or after April 1st.

 

Q:  I did a supplemental form when the patient changed to CAPD within 3 months of their InCenter Hemodialysis start date.  The patient has now switched to CCPD.  Do I need to do another supplemental form?

A:  No.  You do not need to do a new form each time the patient trains on a new modality, only the first time they change to a home or PD modality within 3 months of their initial start.  Modality change information is reported on the monthly Network Patient Activity Report.

 

Q:  What do I do if the patient did not complete their training?

A:  Please contact the Network immediately, especially if the form has already been submitted. 

 

 

Northwest Renal Network

March 7, 2008