End-Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease to function, requiring a regular course of long-term dialysis or a kidney transplant to maintain life.

Dialysis is the process of removing waste products from the body, by diffusion from one fluid compartment to another, across a semi-permeable membrane. Dialysis procedures can include hemodialysis, peritoneal dialysis, hemofiltration, and ultrafiltration. These types of dialysis procedures include two that are commonly used for the treatment of ESRD: hemodialysis and peritoneal dialysis.

Definitions

Hemodialysis - Blood passes through an artificial kidney machine, and the waste products diffuse across a manmade membrane into a bath solution, known as dialysate. The cleansed blood is then returned to the patient’s body. Hemodialysis is accomplished usually in three-to-five-hour sessions, three times per week.

Peritoneal Dialysis - Waste products pass from the patient’s body through the peritoneal membrane into the peritoneal (abdominal) cavity. There, the bath solution (dialysate) is introduced and removed periodically. There are three types of peritoneal dialysis:

• Continuous Ambulatory Peritoneal Dialysis (CAPD): In CAPD, the patient’s peritoneal membrane is used as a dialyzer. The patient connects a 2 to 2.5 liter plastic bag of dialysate to a surgically implanted in-dwelling catheter that allows the dialysate to pour into the beneficiary’s peritoneal cavity. Every four to six hours, the patient drains the fluid out into the same bag and replaces the empty bag with a new bag of fresh dialysate. This is done several times a day.

• Continuous Cycling Peritoneal Dialysis (CCPD): CCPD is a treatment modality that combines the advantages of the long-dwell, continuously steady-state dialysis of CAPD, with the advantages of automation inherent in intermittent peritoneal dialysis. The major difference between CCPD and CAPD is that the solution exchanges, that are performed manually during the day by the patient on CAPD, are moved to nighttime with CCPD and are performed automatically with a peritoneal dialysis cycler. Generally, there are three to seven nocturnal exchanges over eight to 10 hours. Upon awakening, the patient disconnects from the cycler and usually leaves (but not always) the last 2 to 2.5 liter fill inside the peritoneum to continue the daytime long-dwell dialysis.

• Intermittent Peritoneal Dialysis (IPD): Waste products pass from the patient’s body through the peritoneal membrane into the peritoneal cavity where the dialysate is introduced and removed periodically by machine. Peritoneal dialysis generally is required for approximately 30 hours a week, either as three 10-hour sessions or less frequent, but longer, sessions.

According to CMS guidelines for ESRD, candidate eligibility is determined by:

1. The first day of the third month after the month dialysis begins (i.e., the first day of the fourth month of dialysis), demonstrated by claims submissions;
2. The first day of the month dialysis began, if the individual trains for self-dialysis;
3. The month an individual is admitted to a hospital for a kidney transplant, or for health care services needed before a transplant, if the transplant takes place in the same month or within the two following months.

In addition, for a Medicare beneficiary to be assigned an ESRD status, the attending physician must certify the ESRD status of the enrollee by completing a CMS Form CMS-2728-U3. This form must be submitted electronically to CMS’s CROWNWeb system.

Tips for Submitting Eligibility & Evidence Report (2728 Form)

Submission of the CMS “END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION” (also known as the “2728” form) is required for a members ESRD eligibility.

The 2728 form is to be submitted through or completed in the End-Stage Renal Disease (ESRD) Quality Reporting System (EQRS) on CROWNWeb. Key data elements to ensure are included and accurate:

• ESRD chronic date is listed in CROWNWeb, reflecting the date ESRD was diagnosed;
  • Ensure this date coincides with claim date of service.
• Ensure the member’s current Medicare ID (MBI) is listed in EQRS.
• Ensure the patient and doctor signature dates are listed;
  • CMS-2746 ESRD Death Notification Form is required if a patient expires.
• Member’s information is not transmitted to CMS if it is not in “submit” status.

ESRD candidate and eligibility information can be found at the following website locations:

1. Cms.gov: Health Plans General Info (PDF)
2. Cms.gov: End-stage-renal-disease-ESRD-Center
3. Cms.gov: Coordination-of-Benefits-and-Recovery-Overview

If you experience issues with submission or identifying a member in CrownWeb, locate your state contact information at: Esrdncc.org/ESRD-network-map.

Information specific to the provider’s responsibility to update CrownWeb can be found at: Mycrownweb.org/EQRS-Data-Management-Guidelines (PDF).