CMS 2728 Form Misses Four Key Data points

Introduction

CMS gathers reams of kidney patient data on two forms: the CMS 2728, which collects data on individual patients when they start their first dialysis or get a first transplant and the CMS 2744, which collects clinic-level data on patients (not tied to individuals), treatments, and staffing. But, several key data points that could inform our educational efforts are missing.

End Stage Renal Disease Medical Evidence Report (CMS 2728-U3)

The first CMS 2728-U3 form to track data on people with kidney failure was published in 1973 when Medicare started covering dialysis and transplant. The original form has been revised multiple times. The most recent CMS 2728-U3 is dated 6/2024. It is 13 pages long with 68 questions 5 pages worth—plus 2 pages of diagnoses and codes and 7 of instructions. The 2728 was originally a 3-part carbon form completed by hand, with one copy going to Social Security to initiate a Medicare application, one to the ESRD Network for CMS data collection, and one for the patient’s medical record.

Today dialysis clinics or transplant programs complete this form electronically in CMS’ ESRD Quality Reporting System (EQRS). Data from this form are shared with the United States Renal Data System for data analysis and publication of an Annual Data Report. When a patient chooses to apply for Medicare, the clinic prints the form and sends it to the local Social Security office or gives it to the patient to take to that office. When you review the items (Appendix A at the end of this post), you’ll see that I’ve paraphrased some longer questions without changing the meaning.

ESRD Facility Survey (Dialysis Unit Only) (CMS 2744A)

Each CMS-certified outpatient dialysis clinic and transplant program is required to complete an ESRD Facility Survey (CMS 2744) annually in the early spring for the prior calendar year (January 1 through December 31). The most recent revision of these forms is dated July 2020. CMS 2744s are submitted online to the ESRD Network that serves the geographic area where the dialysis facility or transplant program is located. Transplant programs complete a CMS 2744B that provides data on transplants performed and patients awaiting transplants. At the end of this post in Appendix B, you will find the questions asked on the CMS 2744A for dialysis patients and treatments. The 2744 is 11 pages long, with one page of questions and 10 of instructions.

Other Data CMS Should Collect—and Why

Education Level: What is the Last Grade of Schooling You Completed?

Medical Education Institute and many other nonprofit organizations strive to develop patient education materials that are factual, evidence-based, and written at a grade level most patients can read and understand—which tends to be 3-5 grades lower than the last year of schooling completed. So, someone with a 10^th grade education might most easily comprehend materials written at grade 5-7. MEI develops ALL patient education materials at a 5^th to 6^th grade reading level, paragraph by paragraph, to avoid wide variations in reading level. It is helpful for those developing patient education materials to know how much formal education patients tend to have. It helps low-literacy readers to use fewer, smaller words and include pictures, captions, white space, bullets, numbers, and headers to improve comprehension. The 2023 American Community Survey (ACS) asks respondents about their Educational Attainment. In that survey, 10.2% of respondents reported less than a high school diploma, and 4.6% had completed less than 9^th grade. The ACS also reported reading level by age, and older patients were slightly more likely to have completed less than high school. CMS should add this question to the CMS 2728: “What is the last grade of schooling you completed?”

Primary Language: What Language Do You Speak at Home?

The ESRD Conditions for Coverage (CfC) under the Condition: Patients’ Rights states that it is a patient right “to receive all information in a way that he or she can understand.” The 2008 Interpretive Guidance states: “Staff should consider patients’ literacy levels, whether they have communication disorders (low vision/blindness, hearing loss, or speech impairment), and whether a language other than English is their primary language.” The ACS asks respondents Language Spoken at Home. That data show that almost 78% of the U.S. population speak only English at home, while 13.7% speak Spanish, 3.9% speak another Indo-European language, 3.5% speak an Asian language, and 1.3% speak another language. Unfortunately, we don’t know what language(s) patients with kidney disease speak, much less what language(s) they can read. It’s essential for patients to understand treatment options well enough to provide informed consent. And, they need to understand other health information well enough to follow advice from their doctor and other members of their healthcare team. Not knowing what language non-English speakers speak and read limits our ability to provide education that patients can understand. Question #26 on the CMS 2728 asks three questions: “Do you understand health literature in English? Do you need a different way other than written documents to learn about your health? Do you need a translator to understand health information?” Unfortunately, this question doesn’t take the next logical step to ask what the patient’s primary language is. Therefore, CMS should add these two questions to the CMS 2728: “What language do you speak at home?” and “Do you need an interpreter who speaks that language to help you understand health information?”

Assess Health Literacy: Is This Patient’s Health Literacy Adequate, Moderate—or Limited?

Research has shown that poor health literacy contributes to negative outcomes, difficulty with self-management behaviors, increased risk of hospitalizations and death, and poor quality of life.¹ Dialysis clinic staff could easily screen patients for health literacy. They could identify which patients are likely to need additional help to understand education they provide. The Brief Health Literacy Screening Tool asks only four questions and a patient responds using a 5-point Likert scale. The score determines if the patient has adequate, marginal, or limited health literacy. If clinics performed this assessment and CMS collected these data, organizations like MEI that develop patient education materials could target education to better meet the needs of patients with all levels of health literacy. CMS should add this question to the CMS 2728: “What is this patient’s health literacy level: adequate, moderate, or limited?”

Conclusion

The CMS 2728 and 2744 forms collect a wealth of data. Not all of the data are published, but those that are published help researchers to study, educators to educate, and practitioners to intervene to improve the health and lives of people with kidney disease. Adding these four questions to the CMS 2728 could help us achieve better patient outcomes with little effort.

Appendix A: 2728 Form

2728 Section A: Dialysis or transplant programs are supposed to complete this for all ESRD patients and select one of these options:

• “Initial” when a patient starts dialysis or has a transplant

• “Re-entitlement” when a patient who lost Medicare 3 years post-transplant resumes dialysis or gets another transplant

• “Supplemental” when a patient gets a transplant or starts self-care/home dialysis training during the first 3 months of dialysis

The form includes:

1. Patient name

2. Medicare number (if s/he has one)

3. Social Security number

4. Date of birth

5. Patient’s mailing address

6. Patient’s phone number with area code

7. Alternate phone number with area code

8. Sex assigned at birth on original birth certificate

9. Sex you describe yourself (Will this be deleted subject to Trump Executive Order?)

10. Ethnicity

11. Country/area of origin or ancestry

12. Race (several options including multi-racial)

13. Is the patient applying for Medicare?

14. Current medical coverage (several options)

15. Height (inches or centimeters)

16. Dry weight (pounds or kilograms)

17. Primary cause of kidney failure (diagnoses & diagnosis codes on Pages 6-7)

18. Occupation 6 months prior and currently

19. Comorbid conditions current and/or in last 10 years (52 options, completed by physician)

20. Prior to ESRD therapy

1. Receipt of EPO or equivalent before dialysis and how long before

2. Under care of a nephrologist and how long before

3. Seen a kidney dietitian and how long before

4. Type of access for HD, AVF present or not, single needle placed; PD catheter present

5. Diagnosed with AKI in last 12 months

6. Informed about and understood home dialysis options

7. Informed about and understood transplant options, for living donor transplant

8. Informed about not starting dialysis (active medical management without dialysis)

21. Lab values and date either prior (within 45 days of ESRD) or on admission

22. Living will or medical/physician order for life sustaining treatment

23. Concern about where to live over the next 90 days

24. Caregiver support for daily care? With home dialysis or transplant? Does the caregiver live with you?

25. Access to reliable transportation

26. Understanding of health literature in English; need for other than written documents to learn about health; need for a translator to understand health information.

27. Ability to pay for housing, medical care, utilities

28. Food insecurity in the last 12 months

29. Threats of harm or physical hurt from anyone including family or friends in past 12 months

2728 Section B: Dialysis clinics complete this section for all ESRD (not AKI) patients:

30. Dialysis clinic name

31. CMS Certification Number

32. Primary dialysis setting (home, in-center, SNF/LTC)

33. Primary type of dialysis (HD, CAPD, CCPD or other), sessions/week, minutes/session

34. Date of first dialysis

35. Date admitted to the clinic

36. Does patient understand transplant options on admission?

37. Reason(s) patient was not informed about or doesn’t understand transplant options

38. Has patient been referred to a transplant center, date, and transplant center’s name

39. Does patient’s understand home dialysis options on admission?

40. Reason(s) the patient was not informed about or doesn’t understand home dialysis options

2728 Section C: Transplant programs complete this section

41. Date of the transplant

42. Name of the transplant hospital

43. CMS Certification Number

44. Date the patient was admitted as inpatient prior to transplant

45. Name of preparation hospital

46. CMS Certification Number of that hospital

47. Current status of transplant

48. Type of transplant (multiple options)

49. If non-functioning, date of return to regular dialysis

50. Current dialysis setting (home, in-center, SNF/LTC, Transitional Care Unit)

2728 Section D: Dialysis clinics complete this section for self-dialysis (home) training:

51. Name of training provider

52. CMS Certification Number

53. Date training began

54. Type of training

55. Is patient expected to complete (or has completed) training and will self-dialyze regularly

56. Date when patient completed or is expected to complete training

57. Physician certifies Section D is accurate

    1. Printed name

    2. Signature

    3. Date

58. NPI of physician

2728 Section E: Physician identification

59. Attending physician’s name

60. Phone number

61. NPI

Physician attestation: “I certify, under penalty of perjury, that the information on this form is correct to the best of my knowledge and belief. Based on diagnostic tests and laboratory findings, I further certify that this patient has reached the stage of renal impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplant to maintain life. I understand that this information is intended for use in establishing the patient’s entitlement to Medicare benefits and that any falsification, misrepresentation, or concealment of essential information may subject me to fine, imprisonment, civil penalty, or other civil sanctions under applicable Federal laws.”

62. Physician’s signature

63. Date

64. Physician recertification signature (when patient chose not to apply for Medicare and now wishes to, Social Security needs original CMS 2728 or new form)

65. Date

66. Remarks: A physician, patient, Network, or Social Security field office can add notes, including whether the person is re-entering Medicare after loss of Medicare

2728 Section F: Obtain patient’s signature

67. Signature of patient

68. Date

69. If patient is unable to sign/mark (lost to follow up, moved out of U.S./territories, expired)

Appendix B: 2744 Form

1. At the top it says “For The Period”

2. Physical address

3. Number of stations

4. Phone number

5. Ownership (profit or non-profit)

6. Local/National Affiliation/Chain Information

7. Type of dialysis services offered (incenter HD, PD, home HD training)

8. Does your facility offer a dialysis shift that starts at 5:00 p.m. or later?

DIALYSIS PATIENTS AND TREATMENTS

2744: DIALYSIS PATIENTS

Patients Receiving Care Beginning of Survey Period

01. Incenter

02. Home

03. Total (Fields 01 thru 02)

2744 Additions During the Survey Period

• Started dialysis for the first time ever

04A. In-center

04B. Home

• Restarted

05A. In-center

05B. Home

• Transferred from other dialysis unit

06A. In-center

06B. Home

• Returned after transplant

07A. In-center

07B. Home

2744 Losses During Survey Period

• Deaths

08A. In-center

08B. Home

• Recovered Kidney Function

09A. In-center

09B. Home

• Received transplant

10A. In-center

10B. Home

• Transferred to another dialysis unit

11A. In-center

11B. Home

• Discontinued dialysis

12A. In-center

12B. Home

• Other (LTFU)

13A. In-center

13B. Home

2744 Patients Receiving Care at End of Survey Period

• Incenter dialysis

14. Hemodialysis

15. Other

• Self-Dialysis Training

16. Hemodialysis

17. CAPD

18. CCPD

19. Other

• Total Incenter Dialysis

20. Fields 14 thru 19

• Home Dialysis

21. Hemodialysis

22. CAPD

23. CCPD

24. Other

• Total Home Dialysis

25. Fields 21 thru 24

Total Patients

26. Fields 20 and 25

2744 Patient Eligibility Status End of Survey Period

27. Currently enrolled in Medicare

28. Medicare application pending

29. Non-Medicare

2744 Hemodialysis Patients Dialyzing More Than 4 Times Per Week

Setting Day

30A. Incenter

30B. Home

Setting Nocturnal

31A. Incenter

31B. Home

2744 Vocational Rehabilitation

32. Patients aged 18 through 64

33. Patients aged 65 and older

34. Patients receiving services from Voc Rehab

35. Patients Employed full-time or part-time (instructions: patients with taxable earnings)

36. Patients attending school full-time or part-time (instructions: formal ed or training)

TREATMENT AND STAFFING

2744 Incenter Dialysis Treatments (Include Training Treatments)

37. Hemodialysis

38. Other

2744 Staffing

Number of Staff*

39. Full Time (instructions: 32 hours/week)

a. RN

b. LPN/LVNs

c. PCTs

d. APNs

e. Dietitians

f. Social Workers

40. Part Time (instructions: less than 32 hours/week)

a. RN

b. LPN/LVNs

c. PCTs

d. APNs

e. Dietitians

f. Social Workers

Number of Open Pos.

41. Full Time

a. RN

b. LPN/LVNs

c. PCTs

d. APNs

e. Dietitians

f. Social Workers

42. Part Time

a. RN

b. LPN/LVNs

c. PCTs

d. APNs

e. Dietitians

f. Social Workers

Completed by (Name)

Date

Title

Telephone No.

*It is worth noting that the number of staff working in dialysis may be over-counted since a staff person may work full-time at one dialysis clinic and part-time at another or may work part-time at more than one dialysis clinic.