End Stage Renal Disease Quality Reporting System (EQRS)

Medical Evidence Reporting Form (CMS-2728)

A Medical Evidence Reporting Form (CMS-2728) should be completed for all patients undergoing regular dialysis after receiving a diagnosis of ESRD and a prescription has been written for a regular course of dialysis treatment. 

• Facilities have 45-days from the date a patient started at current facility to submit a completed 2728. 

• A 2728 is required even if the patient chooses not to apply for or will not qualify for Medicare. 

• The 2728 should be signed in BLUE ink by both the physician and the patient.

  • If the patient is applying for ESRD Medicare Coverage this BLUE-ink signed copy should be sent to the local Social Security Office.

  • Otherwise the BLUE-ink signed copy should be kept in the patient’s file in the event they apply later.

• Facilities using EQRS:  Data from the form is entered into the EQRS system, and no paper should be submitted to the Network office.

• Facilities not using EQRS (i.e. Veterans Administration, Military, and Transplant units): A copy of the signed form should be submitted to the Network via fax (609.490.0835).

Important Notice Regarding Collection of Race on the CMS-2728

The following instructions regarding the collection of patient race on the CMS-2728 form were recently provided by CMS in CROWN Memo 10-0508-GN:

Ethnicity and race shall be “self-reported” by the patient to be in conformance with current OMB standards. “Self-reported” is defined as the patient’s verbal or written confirmation of ethnicity and race. It is important to note that the current instructions on CMS Form 2728 do not specify that the information on ethnicity and race must be self-reported, and therefore it is likely that in some cases the information is actually “provider-reported.”

CMS instructs the ESRD Networks to educate the ESRD Medicare Provider community on how to correctly document patient ethnicity and race. Whenever possible, providers must document the patient’s self-reported ethnicity (field 8) and race (field 10) on the OMB 2728 Form. In the event that a patient or patient’s family member is unable to self-report their ethnicity and/or race, instruct providers to record this information on behalf of the patient, and acknowledge the absence of the patient’s self-reported ethnicity and race in the remarks area (field 53) by noting that “fields 8-10” were reported by _________.

With the roll-out of the EQRS national release, the ESRD provider community will be required to document whether ethnicity and/or race was self-reported by the patient or by a patient’s family member and if the patient chose not to report their ethnicity and/or race.

Annual Facility Survey (CMS-2744)

The ESRD Annual Facility Survey (CMS-2744) is an annual report that dialysis facilities must turn in to their Network. The survey is designed to capture only a limited amount of information concerning each federally-approved renal facility’s operation. It is not intended to yield information on the full range of ancillary services or activities, e.g., referrals, graft outcome, etc.

Every facility/center approved by Medicare to provide services to ESRD patients must furnish the information requested in the ESRD Facility Survey (42 U.S.C. 426; 20 CFR 405, Section 2133). It is also the facility’s/center’s responsibility to provide patient and treatment counts to their local ESRD Network upon termination of operations. Facilities certified as only providing inpatient services are not requested to complete a survey.

The CMS-2744 lists:

• Patients receiving care at the beginning of the reporting period

• Patients added to the facility during the reporting period

• Patient losses at the facility during the reporting period

• Number of patients present at the facility at the end of the reporting period

• Patients Medicare enrollment status

• Hemodialysis patients dialyzing more than four times per week

• Vocational rehabilitation status of patients

• Number of Hemodialysis and Other treatments in center

• Staffing

You cannot delete the CMS-2744 form once you create it. Once submitted, the ESRD Network will review the CMS-2744 and accept it or reject it. 

Forms and Instructions

• CMS-2744a (For Dialysis Units)

• CMS-2744b (For Transplant Units)

• CMS-2744 Training

ESRD Death Notification Form (CMS-2746)

The ESRD Death Notification Form (CMS-2746) is a one-time form completed when a dialysis patient dies. The purpose of the form is to notify Medicare of the date and cause of a patient's death. The 2746 form is to be completed by the transplant or dialysis center that was last responsible for the care of the patient on an ongoing basis, regardless of the place of death.

Important Tips

• The ESRD facility last responsible for the patient's ongoing care is responsible for completing and submitting the CMS-2746 form if:

  • a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days,

  • a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab

  • a patient dies while dialyzing as a transient.

• Facilities using EQRS: The data from the form is entered into EQRS, and no paper should be submitted to the Network office.

• Facilities not using EQRS (Veterans Administration, Military, and Transplant units):  A copy of the form should be submitted to the Network via fax (610.783.0374).