Network #15 relies on dialysis/transplant facilities to report patient information in a timely and accurate manner. This page is intended to assist facility staff members (Social Workers, Data Contacts, etc.) who submit patient paperwork and data to Network #15.

Telephonic Open Participation Information Call (TOPIC)

In 2006 Network #15 began hosting a series of conference calls designed to improve the quality, accuracy, and timeliness of the data that we receive. These calls provide an opportunity for facilities to learn about CMS/Network forms and to open up discussions between facilities and the Network.

• Reporting Patient Events TOPIC
  
• Next call is not yet Scheduled
  
• Handouts
• Forms Compliance TOPIC
  • Next call is not yet scheduled
  • 2728 Compliance - Sample Action Plans to Increase 2728 Compliance
  • 2746 Compliance - Sample Action Plans to Increase 2746 Compliance

* Note: Many parts of Arizona are on Mountain Time but do not follow Daylight Savings so are an hour earlier. This would mean that when NW 15 schedules a call for 12:00, in AZ this call would begin at 11:00 AM.

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Year-End Survey (2744 Form)
As of March 25, 2008 every facility had faxed their completed 2007 2744-Form to Network #15. Facilities need to keep their original 2744 on file for State Surveyors.

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Medical Evidence Report (2728 Form) - Handouts on 2728 Compliance

• Required for all first-time chronic dialysis patients
• Required for all patients initially receiving kidney transplant instead of dialysis
• Required for patients who stopped dialysis for more than 12 months
• Required for patients who a had functioning transplant for over 3 years but are now returning to dialysis or are receiving another transplant.
• Submit green copy to Network #15 within 45 days of patient's start date at facility
• Submit blue copy to Social Security
• Obtain more blank 2728s from your local Social Security office
• You may use this online 2728 (pdf 6 pgs) - but be sure to have the doctor sign this electronically-generated form in BLUE INK.
• Note: Numbers 18a-c of the 2728 asks about time-frames for pre-dialysis therapies given to patients. The 2728 does not offer the choice 0-6 months prior to dialysis. If this is the correct answer, we ask that you hand-write 0-6 on the 2728 form next to the "yes" box.
• Note: For every patient that is on "in-center hemodialysis" you MUST indicate the frequency and duration of dialysis treatments for question 23.

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GFR Calculators

Algorithm for GFR (pdf - 1 pg) - This summarizes the CMS criteria to determine eligibility for the ESRD program and should be used when determining the chronic status of a patient. The GFR value does not need to go on the 2728 form, but should be calculated to ensure that 2728 forms are submitted only for truly chronic patients.

Below are additional resources regarding the basis for the MDRD formula and how to calculate a GFR using this formula:

www.nkdep.nih.gov/GFR-cal.htm
www.hdcn.com/calcf/gfr.htm
http://nephron.com/mdrd/default.html
www.kidney.org (K/DOQI Clinical Practice Guideline Tab) - Has downloadable GFR calculator and CKD Clinical Action Plan

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Death Notification Form (2746)

Death Notification Form (CMS Form 2746) (pdf - 2 pgs) - You may download and use this form. DO NOT both MAIL AND FAX the 2746, ONE FAX IS SUFFICIENT.

• Must be submitted within 30 days of death
• If a patient discontinues dialysis, or goes to a hospital or other acute care setting, and dies within 30 days, the last chronic dialysis facility is still required to submit a 2746. If patient's last event was a transplant, the transplant clinic is responsible for submitting 2746.
• Handouts on 2746 compliance

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Forms Compliance

CMS has mandated that at least 90% of all Medical Evidence (Form 2728) and Death Notification (Form 2746) forms turned in to Networks must be both on time and complete (compliant).

• Handouts on 2728 Compliance
• Handouts on 2746 Compliance
• Blank Compliance Action Plan (MS Excel)
• Sample Action Plans to Increase 2728 Compliance
• Sample Action Plans to Increase 2746 Compliance

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All PARs should be faxed to Network #15 at 303-860-8392 and are due by the 10th day of the month. NEVER email PARs (or any other patient information).

• PAR Instructions and Tips (pdf -5 pgs) which should be referenced when completing the PAR.
• An Excel Spreadsheet version of the Patient Activity Report (MS Excel -1 pg).
• If you do not have Microsoft Excel you may download this pdf version of the PAR.
  

Tips On Completing The PAR

1. Please PRINT legibly or, better yet, use the Excel Spreadsheet version of the PAR which can be downloaded from our website at http://www.esrdnet15.org/data.htm#big.

2. Always write your 6-digit Medicare Provider Number at the top of the page.  Facilities in AZ always have 03 as the first two digits, CO starts with 06, NM starts with 32, NV starts with 29, UT starts with 46, and WY begins with 53. Do NOT use a 3 or 4 digit “corporate” number. 

3. Include your FULL Provider name. “RCG Dialysis” or “Utah Dialysis” is NOT acceptable.  

4. You should ONLY report patients who have been definitively diagnosed as chronic (end-stage) by a nephrologist.  If a nephrologist is waiting to see if the patient is truly end-stage, you should NOT report this patient on the PAR—until/unless the doctor says the are chronic.

5. Be sure to complete every applicable column on the PAR.  People frequently forget to include the patient’s current modality, and often don’t indicate the sending/receiving facilities (applicable when patients have transferred in or out). 

6. Do NOT report Transfer In/Out events for transients/visitors. Patients who were visiting from another outpatient unit for less than 30 days—with no intention of permanently changing facilities—are transient/visitors.  NEW patients should always be reported regardless of how long they stay.

7. Backup Hemodialysis: PD patients who require backup hemodialysis should be reported on a PAR ONLY if they remain on hemodialysis for longer than 30 days.  In those cases, the modality shift or transfer-in date should reflect the date of the patient’s first backup treatment. 

8. New ESRD vs. Transfer In:  If your facility is the FIRST chronic outpatient unit to provide dialysis, you must list a “New ESRD” event on the PAR and send a 2728. “Transfer In” applies to patients who start outpatient treatments at a different chronic facility and then transfer into your unit (these patients will already have a 2728 form).

9. Interruption in Service vs. Transfer Out: If a patient enters a hospital, rehab facility, or other long-term care unit, this is not a transfer out (even if your facility has “discharged” the patient); this is an interruption in service and should be listed as such on the PAR. Use the date the patient actually left your unit, not 30 days after the patient left, or some other “discharge” date. 

10. Discontinue vs. Death: You must ALWAYS report death events for patients who die after stopping dialysis (within 30 days).  You may list a discontinue event, by itself, when a patient has stopped dialysis and is still living at the time you submit your PAR.

11. Modality shifts:  Modality shift ONLY pertains to people who are still at your unit and have changed the type of dialysis they receive.  ** If your unit only has an incenter hemo department (and no PD department) then you would NEVER have modality shift events. 

12. Restart vs. Resume Service:  Restart applies to people who have completely stopped dialysis for some period of time.  Resume service pertains to patients who were previously reported as interruption in service and are returning from a hospital/acute setting.
    
    
13. Dialysis After Transplant:  Does not apply to “kick-start” dialysis that sometimes follows a kidney transplant. This event is only used when a physician determines that the new kidney has utterly failed and chronic, outpatient dialysis must be administered.

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Transplant Activity Report (TAR)

Each transplant facility in Network #15 needs to turn in a TAR every month to report all kidney transplants that have taken place. The TAR should be faxed to 303-860-8392 and is due by the 10th of the month. The TAR should NEVER be emailed.

• TAR - in Microsoft Excel so that you may save as a spreadsheet and type directly onto the form.
• TAR - this is a pdf version, you may print this out and write on this form.
  

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Patient Events Requiring Forms

Please Note: 501 forms should no longer be used by any facility to report patient events. Rather, patient events are to be reported on the monthly Patient Activity Report (PAR.)

New ESRD Patient - Patient has been diagnosed as ESRD and receives his/her first-ever outpatient, chronic dialysis treatment. A CMS 2728 form must be submitted.

Transfer In, Category A - Patient transfers into dialysis facility having previously dialyzed at an ESRD-Medicare Certified Provider. Reported via the monthly PAR.

Transfer In, Category B - Patient transfers into dialysis facility having previously only dialyzed in another country or in prison. This will be the patients first outpatient, chronic treatment at an ESRD-Medicare Certified Provider. A CMS 2728 form must be submitted.

Restart - Patient previously stopped dialysis treatment and is now resuming long-term, outpatient dialysis. If it has been over 12 months since last treatment, a new 2728 form must be submitted.

Dialysis after Transplant Failed - Patient has rejected a transplant and is receiving his/her first post-transplant, outpatient dialysis. If 3 years have elapsed since transplant occurred requires a new 2728 form - otherwise only reported via PAR.

Transfer-Out for Transplant - Patient leaves facility to receive a transplant. Reported via the monthly PAR.

Transfer Out, Category A - Patient transfers long-term (over 30 days) to another ESRD-Medicare Certified Dialysis Provider. Reported via the monthly PAR.

Transfer Out, Category B - Patient leaves facility to receive long-term (over 30 days) dialysis in another country or prison. Reported via the monthly PAR.

Discontinue - Patient stops dialyzing after specifically articulating the decision to permanently stop dialysis. Facility still needs to track patient for 30 days after discontinue event, and report to Network any status change (death, recover function). If death occurs within 30 days facility is responsible for turning in a 2746 death notification. Reported via the monthly PAR.

Death - May be reported via PAR, or directly from 2746 form. If patient discontinues dialysis or enters long-term care facility, dialysis facility is still responsible for submitting 2746 if death occurs within 30 days.

Recover Function - Patient regains renal function of his/her native kidney and is able to survive without dialysis. Should never be used for patient who has had a kidney transplant. Reported via the monthly PAR.

Modality Change - When patient changes type of dialysis (Hemo to CAPD etc.) Reported via the monthly PAR. NOTE: If patient changes from in-center hemo to PD within 90 days of initial onset of chronic dialysis a Supplemental 2728 is required.

Change of Address for patient - No specific form is required for this event. This information is captured when patients transfer between facilities via the monthly PAR which now asks for patients current zip code.

Transplant - This event requires 2728 from transplant facility only if patient has never been on dialysis, or has had a functioning transplant for more than 36 months.

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Network #15 Reports That are Sent to Dialysis Facilities

Compliance Reports - (aka: Timeliness and Accuracy Reports) CMS mandates that 90% of required forms (2746s and 2728s) are submitted on time and complete. This report shows the percentage of forms received that meet this standard. Report is sent to facilities semiannually and is reviewed by CMS to determine if sanctions against facilities are warranted.

Current Rejects Report - When the Network receives an incomplete 2728 or 2746 form a Rejects Report is generated. This report lists the name and SS# of the patient, the type of form that was received with incomplete information, and an explanation or number of the field which needs to be completed. Facilities need to return Rejects Report with the missing info written on it.

Missing Forms Report - When the Network receives information about patient events via the PAR without receipt of the corresponding 2728 or 2746 form a Missing Forms Report is generated. Facilities need to submit the Missing Form immediately.

Quarterly Roster - Alphabetical list of patients the Network shows to be currently dialyzing at a facility. Sent out quarterly, the roster needs to be reviewed by the facility and returned with a list of any additions or losses.

Tiebreaker Report - A tiebreaker report is sent out when there is a discrepancy between the patient data (i.e. patient name, SS#, DOB) we have at Network #15, and the data from CMS. Please be sure to verify the "element in question" by looking at original patient documents, i.e., social security card or Medicare card. Also, be sure to read any additional information that is included in the body of the fax that is sent along with the tiebreaker report. Then return this report to Network #15 ASAP along with a copy of documentation used to verify correct patient information.

Medicare Reported Deaths - This report is sent out to notify facilities about death events that have been reported to Network #15 via CMS. Facilities are NOT required to return or respond to this report UNLESS the patient is still alive, or had transferred to another licensed, chronic, Medicare dialysis unit prior to death. In those cases we ask that you call us at 303-831-8818.

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Definitions

Please see this complete Glossary (pdf - 4 pgs) for definitions of frequently used data terms.

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Frequently Asked Questions

Q: Is a 2728 still required if a patient dies after only one or two treatments?
A: Yes. If you have a nephrologist that has diagnosed a patient to be chronic, and will sign a 2728 form testifying to this, then you should always complete the 2728 regardless of how long, or short, the patient was on dialysis.

Q: What happens if a patient doesn't sign a 2728 form?
A: If a patient dies before signing the form, a family member should sign for the patient. In those rare instances where a signature is impossible to obtain, facilities should call the Network and ask for Karolyn.

Q: When and how should patients on backup hemodialysis be reported?
A: If a patient is expected to be (or ends up) on backup hemo for longer than 30 days they should be considered a transfer in and as such should be reported on the PAR--UNLESS patient is only receiving occasional (2x or less per week) hemodialysis treatments in addition to their PD treatments; in these cases the backup treatments don't need to be reported.

Q: What happens if a patient enters a long-term care center (i.e. VENCOR) or a hospital?
A: That event is now considered an "Interruption in Service" and may be reported via the Patient Activity Report. That patient is still considered a part of the population, and any status change (death, recover function, transfer to chronic facility) needs to be reported via the PAR. If a patient dies within 30 days of entering an acute facility, the outpatient dialysis unit is still responsible for completing a 2746 form.

Q: What is the difference between the "Current Rejects Report" and the "Missing Forms Report"?
A: The Current Rejects Report is sent when the Network HAS ALREADY RECEIVED a form, but the form is incomplete. The Missing Forms Report is sent when the Network has NOT YET RECEIVED a required form (2728 or 2746) to match a patient event.

Q: Where do facilities obtain blank 2728 and 2746 forms?
A: Local Social Security offices have blank 2728 forms. The Network has blank 2746 forms, or, better yet, you may download the CMS Form 2746 here.

Q: Can facilities fax the 2728 or 2746 forms to the Network?
A: It is always acceptable to fax 2746s. 2728s may be faxed in situations where the hard copy is close to being late, and the facility wants to ensure Network #15 receives it on time. Please DO NOT both fax AND mail any forms - one copy is sufficient.

Q: The State Survey Agency has assigned our unit a provider number with "23" as the middle number, but Network #15 is telling us not to use this number. Why?
A: CMS has issued this letter confirming the policy requiring hospital-based units to use their hospital provider number with 00-08 in the middle rather than the "23" in all correspondence with the ESRD Networks or CMS.

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