67868-0
End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
Trial
Status Information
- Status
- TRIAL
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 | |||
| Indent Indent45394-4 | Patient Last (Family) name | R | ||
| Indent Indent45392-8 | Patient First (Given) name | R | ||
| Indent Indent45393-6 | Middle initial | O | ||
| Indent Indent45397-7 | Medicare or comparable number | R | ||
| Indent Indent45396-9 | Social Security number [Identifier] | R | ||
| Indent Indent21112-8 | Birth date | R | {mm/dd/yyyy} | |
| Indent67871-4 | Patient demographics - end stage renal disease form 2728 | |||
| Indent Indent56799-0 | Address | R | ||
| Indent Indent68997-6 | Patient City (Mailing) | R | ||
| Indent Indent46499-0 | State of residence | R | ||
| Indent Indent45401-7 | Postal code [Location] | R | ||
| Indent Indent42077-8 | Patient phone number | R | ||
| Indent Indent46098-0 | Sex | R | ||
| Indent Indent54133-4 | Ethnicity [USSG-FHT] | O | ||
| Indent Indent68329-2 | Country of origin | C | ||
| Indent Indent54134-2 | Race [USSG-FHT] | R | ||
| Indent Indent67884-7 | Tribal enrollment | C | 0..* | |
| Indent Indent67872-2 | Is the patient applying for ESRD Medicare coverage? | R | 1..* | |
| Indent Indent52556-8 | Payment sources | |||
| Indent Indent8302-2 | Body height | R | [in_us];cm;m | |
| Indent Indent8340-2 | Dry body weight Estimated | R | kg;[lb_av] | |
| Indent Indent67873-0 | Primary Cause of Renal Failure Code | C | ||
| Indent Indent67874-8 | Patient Prior Employment Status (6 Months Prior) | R | ||
| Indent Indent67875-5 | Patient Current Employment Status (At Onset) | R | ||
| Indent Indent67876-3 | Co-Morbid Conditions | R | ||
| Indent Indent67885-4 | Received exogenous erythropoetin or equivalent prior to end stage renal disease therapy | C | ||
| Indent Indent67886-2 | Care by nephrologist prior to end stage renal disease therapy | C | ||
| Indent Indent67887-0 | Care by kidney dietician prior to end stage renal disease therapy | C | ||
| Indent Indent67888-8 | Access Type for First Outpatient Dialysis | C | ||
| Indent Indent68449-8 | Is maturing AVF present? | C | ||
| Indent Indent68450-6 | Is maturing graft present? | C | ||
| Indent68996-8 | Laboratory - end stage renal disease form 2728 | |||
| Indent Indent1751-7 | Albumin [Mass/volume] in Serum or Plasma | O | g/dL | |
| Indent Indent49049-0 | Collection time of Specimen | C | {clock_time} | |
| Indent Indent68900-0 | Albumin Lab Method | O | ||
| Indent Indent2160-0 | Creatinine [Mass/volume] in Serum or Plasma | R | mg/dL | |
| Indent Indent718-7 | Hemoglobin [Mass/volume] in Blood | O | g/dL | |
| Indent Indent4548-4 | Hemoglobin A1c/Hemoglobin.total in Blood | O | % | |
| Indent Indent2093-3 | Cholesterol [Mass/volume] in Serum or Plasma | O | mg/dL | |
| Indent Indent13457-7 | Cholesterol in LDL [Mass/volume] in Serum or Plasma by calculation | O | mg/dL | |
| Indent Indent2085-9 | Cholesterol in HDL [Mass/volume] in Serum or Plasma | O | mg/dL | |
| Indent Indent2571-8 | 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 | |||
| Indent Indent67878-9 | Dialysis facility name | R | ||
| Indent Indent68330-0 | Dialysis facility's CMS Certification Number (CCN) where the patient is receiving care | R | ||
| Indent Indent68442-3 | Primary dialysis setting | R | ||
| Indent Indent68443-1 | Primary type of dialysis | R | ||
| Indent Indent68448-0 | Sessions per Week | R | {#}/wk | |
| Indent Indent68489-4 | Hours per session | R | h/{session} | |
| Indent Indent68358-1 | Date regular chronic dialysis began | R | ||
| Indent Indent68444-9 | Date patient started chronic dialysis at current facility | R | ||
| Indent Indent68360-7 | Has patient been informed of kidney transplant options? | R | ||
| Indent Indent68361-5 | If patient NOT informed of transplant options, please check all that apply. | C | ||
| Indent67883-9 | Transplant information - end stage renal disease form 2728 | |||
| Indent Indent68445-6 | Transplant date | C | ||
| Indent Indent68446-4 | Transplant facility name | C | ||
| Indent Indent67880-5 | Transplant Hospital Federal Provider Number | C | ||
| Indent Indent68447-2 | 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 | ||
| Indent Indent68490-2 | Name of Preparation Hospital | C | ||
| Indent Indent68456-3 | Medicare provider number for item 32 | C | ||
| Indent Indent67882-1 | Current status of transplant | C | ||
| Indent Indent68332-6 | Type of donor | C | ||
| Indent Indent68333-4 | If non-functioning, date of return to regular dialysis | C | ||
| Indent Indent68334-2 | Current dialysis treatment site | C | ||
| Indent68451-4 | Self-dialysis training program - end stage renal disease form 2728 | |||
| Indent Indent68335-9 | Self-dialysis training facility name Dialysis facility | C | ||
| Indent Indent67881-3 | Self-dialysis Training Facility Federal Provider Number | C | ||
| Indent Indent68362-3 | Date training began. | C | ||
| Indent Indent68336-7 | Type of training | C | ||
| Indent Indent68337-5 | Location of training | C | ||
| Indent Indent68338-3 | This patient is expected to complete training and will self-dialyze on a regualr basis | C | ||
| Indent Indent68339-1 | Date when patient completed, or is expected to complete training | C | ||
| Indent Indent68491-0 | Training Physician Name | C | ||
| Indent Indent68355-7 | Date | C | ||
| Indent Indent68357-3 | Self-dialysis training physician NPI Provider | C | ||
| Indent68462-1 | Physician information - end stage renal disease form 2728 Provider | |||
| Indent Indent52526-1 | Attending physician name | R | ||
| Indent Indent68340-9 | Attending physician phone number | R | ||
| Indent Indent68468-8 | Attending physician NPI Provider | R | ||
| Indent Indent68355-7 | Date | R | ||
| Indent Indent8251-1 | Service comment | O | ||
| Indent Indent68355-7 | Date | R | ||
| Indent Indent65838-5 | Date submitted | R |
LOINC Names Get Info
- Fully-Specified Name
- End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728:
-: Pt: ^Patient: -: - Long Common Name
- End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
Part Model Get Info
- Component
- End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728
LP134062-1
- Analyte
- End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728
LP134062-1
- Component Numerator
- End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728
LP134062-1
- Component Numerator Core
- End stage renal disease medical evidence report, medicare entitlement &or patient registration - OMB CMS form 2728
LP134062-1
- Component Numerator Core Suffix
- NULL
- Component Denominator
- NULL
- Component Denominator Core
- NULL
- Component Denominator Core Suffix
- NULL
- Challenge
- NULL
- Adjustment
- NULL
- Count
- NULL
- Property
- -
LP6769-6
- Time
- Pt
LP6960-1
- Time Core
- Pt
LP6960-1
- Time Modifier
- NULL
- System
- ^Patient
LP310005-6
- System Core
- NULL
- Super System
- Patient
LP6985-8
- Scale
- -
LP7747-1
- Method
- NULL
Basic Attributes
- Class
- PANEL.SURVEY.ESRD
- Type
- Surveys
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=67868-0 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/67868-0
LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://