CMS Form 2728
ESRD Medical Evidence Report
Instructions for
completing the 2728
CMS 2728
Check type of form: initial, reentitlement or supplemental.
Fields 1 - 4
 Patients legal name is required.
 Medicare and social security numbers
are requested but not required.
 Date of birth is a required field.

CMS 2728
Fields 5 – 10
 The patient’s complete mailing address is
required as well as the sex and ethnicity.
 The country of origin is required if Native
Hawaiian or Other Pacific Islander is the race.
 The race is required for all patients. You must
select at least one race code for Hispanic
patients.
CMS 2728
Fields 12 - 15
 The patient’s current medical coverage is
required.
 The height is required even if the patient is a
bilateral amputee. Use the height prior to
amputation in this case.
 The dry weight is required.
 The primary cause is required and only the
codes listed on the form can be used.
CMS 2728
Fields 16 and 17
 Employment status is requested and
both columns should be checked.
 Co-morbid conditions – you should
check all that apply.
CMS 2728
Fields 18a – 18c
 If you answer yes, you must select a
timeframe of either 6 – 12 months, > 12
months or one that is not listed < 6 months.
Field 18d
 If you select catheter as the first access used
as an outpatient, you must answer the two
sub questions.
 If you select graft as the first access used as
an outpatient, you must answer the first sub
question.
CMS 2728
Field 19
 Lab Values – The serum creatinine is
the only required lab and should be
within 45 days prior to the date regular
chronic dialysis began.
 If the other labs are provided they must
be within the specified guidelines.
CMS 2728
Fields 20 – 27
 Complete for all patients in dialysis treatment.
 If the patient is on hemodialysis, you must
provide the sessions per week and the hours
per session.
 If the patient has not been informed of
kidney transplant options, you must select
the reason(s) why in field 27.
CMS 2728
Fields 28 – 37 Section C
 Complete for all Kidney Transplant Patients
 If you are unsure of the Medicare provider
number(fields 30 and 33) for transplant
facilities, contact the Network for assistance.
 Field 36 should be the same date as field 24
if the patient is returning to dialysis following
the failure of a transplant.
CMS 2728
Fields 38 – 45 Section D
 Complete for all ESRD Self-Dialysis Training
Patients
 The date training began can be no more than
30 days prior to the date the patient started
at your facility.
 If the patient is unable to complete training,
this section should not be completed and a
home dialysis setting should not be chosen.
 The physician must sign in field 44B.
CMS 2728
Fields 46 – 53 Physician
Identification
 Always provide the physician’s name
and UPIN. This information is needed
when the signature is illegible.
 The physician must sign line 49.
CMS 2728
Fields 54 and 55
 The patient or his/her representative
must sign and date here.
 If the patient dies before a signature
can be obtained, submit without a
signature and provide the date of
death.
CMS 2746
Instructions for completion of the
2746 form
CMS 2746
Fields 1 – 6
 The basic demographic data of name,
Medicare number, sex, date of birth,
SSN and state of residence is needed to
correctly identify the patient.
CMS 2746
Field 7
 You must select one option a – e
Field 8
 The date of death is required
CMS 2746
Fields 9 – 11
 This is information specific to the facility
that is needed.
CMS 2746
Field 12
 The primary cause of death is required
and you must choose from the codes
listed on the form.
 If code 98 is used, you must provide a
narrative in field 12c.
 Provide a secondary code if available
CMS 2746
Field 13
 If answered “yes”, you must selection
one of options a – e and provide the
date of last dialysis in field 13f.
Field 14
 Answer if applicable
CMS 2746
Field 15
 Answer a, b, c and d if applicable
Field 16
 Answer if applicable
CMS 2746
Field 17
 Only the name of the physician is
required, not a signature. The name
must be legible.
Field 18
 The name of the person completing the
form should be provided in this field.
CMS Form 2728/2746 Review
Completed
You are now ready for the next step
which is to review the
Root Cause Flowchart.