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Data Manual

Target Audience: Dialysis staff responsible for filling out CMS Eligibility or Death Notices, and monthly PARs (Patient Activity Reports)

These instructions are intended to help you successfully understand the CMS 2728 Eligibility Form, the CMS 2746 Death Form, the CMS 2744 Annual Facility Survey Form, and the Patient Activity Report.

If the instructions are unclear or omit specific information, please contact Glenda Whittle at 816-880-1706 for assistance. Please remember that submitting forms with missing or inaccurate information will count against your facility's Forms Compliance Score that is measured every January and July.

• Primary Causes of Renal Failure spreadsheet (grid of old and new codes)
• How forms errors are identified.
• Sample CMS-2728 with lab ranges and recommended uses.
• Blank copy of CMS-2728 for your use.
• Blank copy of CMS-2746
• Forms Manual, also called the "Data Manual". (We recommend that you save this Word document to your local computer for easier navigation with the built in hyperlinked menu. Click on FILE | SAVE AS and save it to a folder on your computer.
• Blank PAR (Patient Activity Report
• PAR Instructions
• Patient Event Categories and their usage on the PAR.
• What to do with Acute Patients and Form 2728s

© 2010 End-Stage Renal Disease (ESRD) #12 Network Coordinating Council, Inc. dba Heartland Kidney Network
This resource was (created, developed, compiled, etc.) while under contract with Center for Medicare and Medicaid Services, Baltimore, Maryland. Contract #HHSM-500-2006-NW012C. The contents presented do not necessarily reflect CMS policy.