Starting PD & Medicare: A Flush is NOT Enough

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on March 3rd, 2014.
Starting PD & Medicare: A Flush is NOT Enough

When a new patient starts treatment for ESRD, his or her dialysis clinic must complete the CMS 2728 in CROWNWeb. CMS 2728 data automatically go to CMS whether the patient already has Medicare or not. (If the patient is not applying for Medicare at that time, the clinic does not send the paper CMS 2728 to Social Security.)

Besides demographic and clinical data, the CMS 2728 asks for treatment type and dates. This information is used to determine if the patient who is applying for Medicare may be eligible for backdating of Medicare based on self-dialysis training or transplant. The form is 6 pages long and includes 3 pages of instructions.

The instructions for Field 24 (first date of dialysis) state:

Enter the date (month, day, year) that a "regular course of chronic dialysis" began. The beginning of the course of dialysis is counted from the beginning of regularly scheduled dialysis necessary for the treatment of end stage renal disease (ESRD) regardless of the dialysis setting. The date of the first dialysis treatment after the physician has determined that this patient has ESRD and has written a prescription for a "regular course of dialysis" is the "Date Regular Chronic Dialysis Began" regardless of whether this prescription was implemented in a hospital/inpatient, outpatient, or home setting and regardless of any acute treatments received prior to the implementation of the prescription.

NOTE: For these purposes, end stage renal disease means irreversible damage to a person’s kidneys so severely affecting his/her ability to remove or adjust blood wastes that in order to maintain life he or she must have either a course of dialysis or a kidney transplant to maintain life.

If re-entering the Medicare program, enter beginning date of the current ESRD episode. Note in Remarks, Item 53, that patient is restarting dialysis.

Field 40 asks for the date that self-dialysis training started, if applicable.

Field 43 asks when self-dialysis training was or will be completed. The form can be found here.

Some clinics have been counting the first PD catheter flush as the first dialysis day. Wrong! The Medicare Benefit Policy Manual provides definitions in §10 for hemodialysis and PD, as follows:

A. Dialysis

Dialysis is the process of removing waste products from the body by diffusion from one fluid compartment to another across a semi-permeable membrane. There are two types of renal dialysis procedures in common clinical usage: hemodialysis and peritoneal dialysis. Both hemodialysis and peritoneal dialysis are acceptable modes of treatment for ESRD under Medicare.

2. Peritoneal

Waste products pass from the patient's body through the peritoneal membrane into the peritoneal (abdominal) cavity where the bath solution (dialysate) is introduced and removed periodically. See §50.A.4 of this chapter for payment information.

A PD catheter is placed surgically. The home training nurse performs catheter flushes while the catheter is healing. This assures that the catheter isn't blocked with fibrin or omentum. A flush does not meet the definition of dialysis, so the facility cannot count this flush as the first day of "dialysis" on the CMS 2728. Unless the patient needs PD urgently, the first day of dialysis may not take place for 2 weeks or more after PD catheter placement.

If a patient does need urgent dialysis, a PD patient lying in a supine position can use a cycler to do several low volume dialysate exchanges three or more times a week. See this article for details. The clinic would report the first treatment PD date on the CMS 2728, and home training could start that day or later.

Patients with ESRD can qualify for Medicare if they have enough work credits or have a spouse or parent with enough work credits. They must apply for coverage through Social Security and the CMS 2728 provides medical documentation of their ESRD status and key dates that will determine when Medicare starts.

You can use this calculator to see when Medicare coverage can start based on when a patient begins a self/home dialysis training program. The form also includes the date the patient completed or will complete training. The patient's doctor must sign the CMS 2728 attesting to its accuracy. The ESRD Conditions for Coverage at § 494.100 Condition: Care at home addresses the requirements for certified training and support facilities.

Is your patient underinsured? Careful scheduling of access placement (PD or HD), training start, (HD or PD), and the first day of dialysis can help. Here's how it works:


  • Fred has a PD catheter (or HD access) placed on December 14.
  • His first PD (or HD) treatment is January 2.
  • Even if he starts a home training program that day, Medicare will only backdate to January 1—so any December charges will not be Medicare covered.

However, if Fred had his PD catheter (or HD access) placed on December 14 and started PD (or HD) on December 31, as long as Fred started home training before March 1, Medicare could cover his December bills.

As you can see, timing is key to whether your patient could incur a large medical debt, or whether Medicare will cover the access placement surgery, lab tests, and more.


  1. Medicare Benefit Policy Manual, Chapter 11- End Stage Renal Disease (ESRD)
  2. Mehrotra R, Crabtree J. PD Catheter Placement and Management.


  • Beth Witten

    Mar 10, 3:56 PM

    In my experience working in dialysis, assessing the catheter patency has been called a "flush" and several websites describing catheter care following surgery call it this. How long is the dwell time, how much fluid and toxins are removed, and how much time is spent teaching technique when assessing the catheter for patency? Medicare 's manuals provide a guideline for what is expected so far as training for PD, but it doesn't discuss expectations when the catheter is assessed for patency. Perhaps that's because unless the patient is receiving urgent start PD, assessing catheter patency occurs before the first full training day and PD treatment.

    The blog provides the Medicare definition of dialysis and PD specifically. The Medicare Benefit Policy Manual Section 30.2, describes Medicare coverage for home training. It states that a CAPD or CCPD training session may last up to 8 hours per session (day) and CAPD training sessions may be performed 5-6 days/week and CCPD training sessions may be performed 5 days/week. Although Medicare requires no specific number of exchanges per training day for CAPD or CCPD, the manual states that in a training session (day) 6-8 exchanges may be performed to teach patients CAPD and 5 exchanges may be performed to teach patients CCPD. Medicare routinely covers 15 training days. Does this sound like what occurs during a PD catheter patency assessment?

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  • Candace Regua

    Mar 10, 1:15 PM

    I disagree. The first time that the catheter is assessed for patency is typically one week post catheter placement. There is a great deal of training that goes on during that patient visit and dwell time, thus dialysis, is easily delivered if the solution and dwell time are managed appropriately. Calling this a "flush" is the problem. Using the time to deliver dialysis means we don't have to wait 2 weeks or longer for training.

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