Version 2.77

Status Information


Part Description

LP134062-1   End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728
Form CMS-2728-U3 - ESRD Medical Evidence Report, Medicare Entitlement, (Patient Registration) is completed on each incident ESRD patient or each patient re-entering the Medicare program. Dialysis and transplant facilities must submit this form to the Networks within 45 days from the date a patient is diagnosed with ESRD and either has a transplant or begins a regular course of dialysis. This form is also mandatory if a patient loses Medicare coverage and re-applying for benefits. Source: Regenstrief LOINC, Medicare ESRD Network Organizations Manual

Reference Information

Type Source Reference
Original Form Centers for Medicare & Medicaid Services CMS-2728-U3 - ESRD Medical Evidence Report, Medicare Entitlement, and/or Patient Registration OMB CMS form 2728

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
Indent67869-8 Form Type Indicator R
Indent67870-6 Patient information
IndentIndent45394-4 Patient Last (Family) name R
IndentIndent45392-8 Patient First (Given) name R
IndentIndent45393-6 Middle initial O
IndentIndent45397-7 Medicare or comparable number R
IndentIndent45396-9 Social Security number [Identifier] R
IndentIndent21112-8 Birth date R {mm/dd/yyyy}
Indent67871-4 Patient demographics - end stage renal disease form 2728
IndentIndent56799-0 Address R
IndentIndent68997-6 Patient City (Mailing) R
IndentIndent46499-0 State of residence R
IndentIndent45401-7 Postal code [Location] R
IndentIndent42077-8 Patient phone number R
IndentIndent46098-0 Sex R
IndentIndent54133-4 Ethnicity [USSG-FHT] O
IndentIndent68329-2 Country of origin C
IndentIndent54134-2 Race [USSG-FHT] R
IndentIndent67884-7 Tribal enrollment C 0..*
IndentIndent67872-2 Is the patient applying for ESRD Medicare coverage? R 1..*
IndentIndent52556-8 Payment sources
IndentIndent8302-2 Body height R [in_us];cm;m
IndentIndent8340-2 Dry body weight Estimated R kg;[lb_av]
IndentIndent67873-0 Primary Cause of Renal Failure Code C
IndentIndent67874-8 Patient Prior Employment Status (6 Months Prior) R
IndentIndent67875-5 Patient Current Employment Status (At Onset) R
IndentIndent67876-3 Co-Morbid Conditions R
IndentIndent67885-4 Received exogenous erythropoetin or equivalent prior to end stage renal disease therapy C
IndentIndent67886-2 Care by nephrologist prior to end stage renal disease therapy C
IndentIndent67887-0 Care by kidney dietician prior to end stage renal disease therapy C
IndentIndent67888-8 Access Type for First Outpatient Dialysis C
IndentIndent68449-8 Is maturing AVF present? C
IndentIndent68450-6 Is maturing graft present? C
Indent68996-8 Laboratory - end stage renal disease form 2728
IndentIndent1751-7 Albumin [Mass/volume] in Serum or Plasma O g/dL
IndentIndent49049-0 Collection time of Specimen C {clock_time}
IndentIndent68900-0 Albumin Lab Method O
IndentIndent2160-0 Creatinine [Mass/volume] in Serum or Plasma R mg/dL
IndentIndent718-7 Hemoglobin [Mass/volume] in Blood O g/dL
IndentIndent4548-4 Hemoglobin A1c/ in Blood O %
IndentIndent2093-3 Cholesterol [Mass/volume] in Serum or Plasma O mg/dL
IndentIndent13457-7 Cholesterol in LDL [Mass/volume] in Serum or Plasma by calculation O mg/dL
IndentIndent2085-9 Cholesterol in HDL [Mass/volume] in Serum or Plasma O mg/dL
IndentIndent2571-8 Triglyceride [Mass/volume] in Serum or Plasma O mg/dL
Indent67877-1 End stage renal disease (ESRD) patients in dialysis treatment - end stage renal disease form 2728
IndentIndent67878-9 Dialysis facility name R
IndentIndent68330-0 Dialysis facility's CMS Certification Number (CCN) where the patient is receiving care R
IndentIndent68442-3 Primary dialysis setting R
IndentIndent68443-1 Primary type of dialysis R
IndentIndent68448-0 Sessions per Week R {#}/wk
IndentIndent68489-4 Hours per session R h/{session}
IndentIndent68358-1 Date regular chronic dialysis began R
IndentIndent68444-9 Date patient started chronic dialysis at current facility R
IndentIndent68360-7 Has patient been informed of kidney transplant options? R
IndentIndent68361-5 If patient NOT informed of transplant options, please check all that apply. C
Indent67883-9 Transplant information - end stage renal disease form 2728
IndentIndent68445-6 Transplant date C
IndentIndent68446-4 Transplant facility name C
IndentIndent67880-5 Transplant Hospital Federal Provider Number C
IndentIndent68447-2 Date patient was admitted as an inpatient to a hospital in preparation for, or anticipation of, a kidney transplant prior to the date of the actual tranplantation O
IndentIndent68490-2 Name of Preparation Hospital C
IndentIndent68456-3 Medicare provider number for item 32 C
IndentIndent67882-1 Current status of transplant C
IndentIndent68332-6 Type of donor C
IndentIndent68333-4 If non-functioning, date of return to regular dialysis C
IndentIndent68334-2 Current dialysis treatment site C
Indent68451-4 Self-dialysis training program - end stage renal disease form 2728
IndentIndent68335-9 Self-dialysis training facility name Dialysis facility C
IndentIndent67881-3 Self-dialysis Training Facility Federal Provider Number C
IndentIndent68362-3 Date training began. C
IndentIndent68336-7 Type of training C
IndentIndent68337-5 Location of training C
IndentIndent68338-3 This patient is expected to complete training and will self-dialyze on a regualr basis C
IndentIndent68339-1 Date when patient completed, or is expected to complete training C
IndentIndent68491-0 Training Physician Name C
IndentIndent68355-7 Date C
IndentIndent68357-3 Self-dialysis training physician NPI Provider C
Indent68462-1 Physician information - end stage renal disease form 2728 Provider
IndentIndent52526-1 Attending physician name R
IndentIndent68340-9 Attending physician phone number R
IndentIndent68468-8 Attending physician NPI Provider R
IndentIndent68355-7 Date R
IndentIndent8251-1 Service comment O
IndentIndent68355-7 Date R
IndentIndent65838-5 Date submitted R

Fully-Specified Name

End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728

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Last Updated
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