Network Data Reporting for Dialysis Facilities and Transplant Centers

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Network Data ReportingforDialysis
FacilitiesandTransplant Centers
The Renal Network Inc.
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Forms and Reports

• CMS-2728
• CMS-2746
• CMS-2744
• Monthly Patient Activity Report
• Quarterly Census Verification

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CMS-2728
END STAGE RENAL DISEASE MEDICAL EVIDENCE
REPORT MEDICARE ENTITLEMENT AND/OR PATIENT
REGISTRATION
This form MUST BE completed within 45 days for
ALL the following

• Patients who start a regular course of dialysis
  for the first time ever
• Patients who initially receive a kidney
  transplant instead of a course of dialysis
• Patients 3 or more years post transplant who
  return to dialysis or receive another kidney
  transplant
• Patients who stopped dialysis more than 12
  months ago and are now restarting dialysis or
  receiving a kidney transplant
• Patients who receive a transplant or are
  trained for self-care dialysis within the first 3
  months of starting dialysis and submitting an
  initial form

Dont forget to send a copy of the form to Social
Security as well as the Network.
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For patients returning to dialysis or receiving a
kidney transplant either 3 years post transplant
or more than 12 months after stopping dialysis.
Patients starting a regular course of dialysis or
receiving a kidney transplant for the first time
ever
Patient has received a transplant or trained for
self-care dialysis within the first 3 months of
starting dialysis
Items circled in RED are mandatory
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Current Medical Coverage, Height, Dry Weight,
Primary Cause of Renal Failure, Employment
Status are all mandatory items that people often
forget to answer.
Leave Blank if Less Than 6 Months
Be sure you answer every question under 18
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Lab Dates MUST be within 45 days PRIOR to Date
Regular Dialysis Began or Transplant Date
All Forms MUST have Serum Creatinine Value
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Be sure to fill in sessions per week and hours
per session for hemodialysis patients
Date used to calculate compliance. Form must be
received by the Network within 45 days of this
date.
If answer to 26 is No, then you must complete 27
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Enter Date of Most Recent Transplant
Must complete for patients returning to dialysis.
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Complete This Section For Patients Receiving
Self-Dialysis Training
43 Date When Patient Completed, or is Expected
to Complete, Training is often left blank by
mistake.
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All Forms MUST Be Signed By The Physician
Date cant be before the date in 24 Date
Regular Chronic Dialysis Began
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Date cant be before the date in 24 Date
Regular Chronic Dialysis Began
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
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CMS-2746ESRD DEATH NOTIFICATION
This form MUST BE completed within 30 days of the
Date of Death
The Network receives notification of patient
deaths from CMS almost every day. We are asked
to verify the information, which comes from the
Social Security database, by contacting the last
facility of record for the patient. This is
accomplished by faxing a list of these patients
to the facility and asking them to verify the
information and send us the 2746 form if
necessary. We believe this will help improve our
compliancy rates since it can sometimes be
difficult for facilities to keep track of
patients who may be in the hospital or nursing
home.
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CMS-2746ESRD DEATH NOTIFICATION
Items circled in RED are mandatory
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CMS-2746ESRD DEATH NOTIFICATION
If cause is Other (98) then Item 12.C must be
answered
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CMS-2746ESRD DEATH NOTIFICATION
If you checked Yes, dont forget to enter the
date in 13.f.
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CMS-2746ESRD DEATH NOTIFICATION
Does NOT require a physician signature. Whoever
completed the form needs to sign it.
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CMS-2744Annual Facility Survey

• Year end summary
• Network mails form to each facility along with
  yearly events report and ending patient census
• Facility makes necessary corrections using the
  events and census reports
• Facility completes remaining items on form
• Form is returned to Network by due date
• Network completes data entry and sends to CMS

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CMS-2744How To Prepare

• Verify the data in each quarterly report to
  ensure an accurate year end census
• Develop a method for tracking yearly treatment
  totals. Check with billing department.
• Keep a list of patients referred to Vocational
  Rehabilitation during the year
• Report your data accurately and timely to the
  Network throughout the year

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Monthly Patient Activity Reports

• List of patient events during the month
• Due by 10th of the following month
• Provider number and name and month/year reported
  must all be on the form
• Fill in all necessary information for each event
• Type or print neatly to avoid processing delays
• No acute or transient patients
• Transfer outs include where they went

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Monthly Patient Activity Reports

• When reporting a New ESRD Patient event please
  send the 2728 form
• When reporting a Death event please send the 2746
  form
• If you have events to report for the month, write
  No Activity on the report and fax it in.

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Quarterly Reports

• Network mails reports to each facility
• Patient events during the quarter
• Patient census at end of quarter
• Verify the data in each report and make
  corrections as needed
• Return updated reports to the Network by the due
  date