Identification Number:
DI 24555 TN 04
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Evaluation of Specific Issues - Genitourinary Impairments
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part 04 - Disability Insurance
Chapter 245 - Medical Evaluation
Subchapter 55 - Evaluation of Specific Issues - Genitourinary Impairments
Transmittal No. 04, 06/2018

Audience

PSC: DE, DEC
OCO-ODO: DE, DEC, DS, RECONE
OCO-OEIO: CR, ERE, FDE, RECONE
ODD-DDS: ADJ, DHU

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal provides information on using the Centers for Medicare and Medicaid Services (CMS) form CMS-2728-U3 "End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration" to meet listing 6.03 or 106.03.

Summary of Changes

DI 24555.010 Using the Centers for Medicare & Medicaid Services (CMS) Form CMS-2728-U3 to Meet Listing 6.03 or 106.03

This new Program Operations Manual System (POMS) section explains the requirements and exceptions for using form CMS-2728-U3 to meet listing 6.03 or 106.03 of the Listing of Impairments. We have incorporated the guidance in National Q&A 10-77 Rev 9.


DI 24555.010 Using the Centers for Medicare & Medicaid Services (CMS) Form CMS-2728-U3 to Meet Listing 6.03 or 106.03

A. Form CMS-2728-U3

Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) is the primary documentation that a person has end stage renal disease (ESRD) for purposes of ESRD Medicare entitlement. The person’s physician, or, at times, the dialysis center, completes the form to document the information needed to determine the person’s eligibility for ESRD Medicare.

This section provides information about using form CMS-2728-U3 to establish that chronic renal disease (CKD) meets the chronic hemodialysis or peritoneal dialysis criterion in listing 6.03 or 106.03 of the Listing of Impairments.

B. Requirements for using the CMS-2728-U3 to meet listing 6.03 or 106.03

An adjudicator may use the CMS-2728-U3 to make a fully favorable determination based on meeting listing 6.03 or 106.03, if the medical source completes certain items on the form. Items 1-14 should be completed in all cases, but non-completion of these items does not preclude using the form to make a determination.

To meet listing 6.03 or 106.03 using the CMS-2728-U3, the following four items must be complete:

  • Item 15 (Primary Cause of Renal Failure): However, if certain diagnosis codes are present in Item 15 (see DI 24555.010C in this section), we cannot make a fully favorable determination without additional evidence that shows that the renal disease is chronic and will meet the duration requirement,

  • Item 19 (Laboratory Values Within 45 Days Prior to the Most Recent ESRD Episode),

  • Item 24 (Date Regular Chronic Dialysis Began) or Item 25 (Date Patient Started Chronic Dialysis at Current Facility), and

  • Item 49 (Attending Physician's Signature of Attestation) – A physician must sign the form. Acceptable signatures include handwritten and electronic signatures. A stamped signature does not satisfy this requirement.

In addition, if the form is the only evidence used for an allowance, a physician must have completed the CMS-2728-U3 no more than 12 months prior to the date of filing. If the physician signed the form more than 12 months before the date of filing, call the dialysis center to confirm that the person is still receiving dialysis.

C. Exceptions to using the CMS-2728-U3 to meet listing 6.03 or 106.03

Do not use the CMS-2728-U3 as the only evidence to establish that the impairment meets listing 6.03 or 106.03 if:

  • The allowance based on meeting listing 6.03 or 106.03 is not fully favorable, or

  • The ICD-9 (International Classification of Diseases, Ninth Revision) or ICD-10 (International Classification of Diseases, Tenth Revision) diagnosis code in Item 15 indicates that the renal disease or kidney failure may be acute or may improve. See DI 24555.010C.1. and DI 24555.010C.2. in this section for ICD-10 and ICD-9 codes that may indicate that dialysis may be acute or may not last for a period of 12 months. If one of these diagnosis codes is present in Item 15, we need additional evidence to show that the renal disease is chronic and will meet the duration requirement.

1. ICD-10 Code Exceptions

ICD-10 Code

ICD-10 Code Description

B20

Human immunodeficiency virus [HIV] disease

C90.00

Multiple myeloma not having achieved remission

D57.3

Sickle-cell trait

D59.3

Hemolytic-uremic syndrome

I70.1

Atherosclerosis of renal artery

K76.7

Hepatorenal syndrome

M31.0

Hypersensitivity angiitis

M31.31

Wegener's granulomatosis with renal involvement

M34

Systemic sclerosis [scleroderma]

M34.0

Progressive systemic sclerosis

M34.1

CR(E)ST syndrome

M34.2

Systemic sclerosis induced by drug and chemical

M34.8

Other forms of systemic sclerosis

M34.81

Systemic sclerosis with lung involvement

M34.82

Systemic sclerosis with myopathy

M34.83

System sclerosis with polyneuropathy

M34.89

Other systemic sclerosis

M34.9

Systemic sclerosis, unspecified

N00.8

Acute nephritic syndrome with other morphologic changes

N03.9

Chronic nephritic syndrome with unspecified morphologic changes

N10

Acute pyelonephritis

N13.9

Obstructive and reflux uropathy, unspecified

N17

Acute kidney failure

N17.0

Acute kidney failure with tubular necrosis

N17.1

Acute kidney failure with acute cortical necrosis

N17. 2

Acute kidney failure with medullary necrosis

N17.8

Other acute kidney failure

N17.9

Acute kidney failure, unspecified

N19

Unspecified kidney failure

N20

Calculus of kidney and ureter

N20.0

Calculus of kidney

N20.1

Calculus of ureter

N20.2

Calculus of kidney with calculus of ureter

N20.9

Urinary calculus, unspecified

N21

Calculus of lower urinary tract

N21.0

Calculus in bladder

N21.1

Calculus in urethra

N21.8

Other lower urinary tract calculus

N21.9

Calculus of lower urinary tract, unspecified

N22

Calculus of urinary tract in diseases classified elsewhere

N23

Unspecified renal colic

N28

Other disorders of kidney and ureter, not elsewhere classified

N28.0

Ischemia and infarction of kidney

N28.1

Cyst of kidney, acquired

N28.8

Other specified disorders of kidney and ureter

N28.81

Hypertrophy of kidney

N28.82

Megaloureter

N28.83

Nephroptosis

N28.84

Pyelitis cystica

N28.85

Pyeloureteritis cystica

N28.86

Ureteritis cystica

N28.89

Other specified disorders of kidney and ureter

O12.10

Gestational proteinuria, unspecified trimester

O12.20

Gestational edema with proteinuria, unspecified trimester

O26.839

Pregnancy related renal disease, unspecified trimester

O90.4

Postpartum acute kidney failure

R69

Illness, unspecified

T86.00

Unspecified complication of bone marrow transplant

T86.10

Unspecified complication of kidney transplant

T86.13

Kidney transplant infection

T86.19

Other complication of kidney transplant

T86.20

Unspecified complication of heart transplant

T86.21

Heart transplant rejection

T86.22

Heart transplant failure

T86.23

Heart transplant infection

T86.29

Other complications of heart transplant

T86.290

Cardiac allograft vasculopathy

T86.298

Other complications of heart transplant

T86.3

Complications of heart-lung transplant

T86.30

Unspecified complication of heart-lung transplant

T86.31

Heart-lung transplant rejection

T86.32

Heart-lung transplant failure

T86.33

Heart-lung transplant infection

T86.39

Other complications of heart-lung transplant

T86.4

Complications of liver transplant

T86.40

Unspecified complication of liver transplant

T86.41

Liver transplant rejection

T86.42

Liver transplant failure

T86.43

Liver transplant infection

T86.49

Other complications of liver transplant

T86.5

Complications of stem cell transplant

T86.8

Complications of other transplanted organs and tissues

T86.81

Complications of lung transplant

T86.810

Lung transplant rejection

T86.811

Lung transplant failure

T86.812

Lung transplant infection

T86.818

Other complications of lung transplant

T86.819

Unspecified complication of lung transplant

T86.82

Complications of skin graft (allograft) (autograft)

T86.820

Skin graft (allograft) rejection

T86.821

Skin graft (allograft) (autograft) failure

T86.822

Skin graft (allograft) (autograft) infection

T86.828

Other complications of skin graft (allograft) (autograft)

T86.829

Unspecified complication of skin graft (allograft) (autograft)

T86.83

Complications of bone graft

T86.830

Bone graft rejection

T86.831

Bone graft failure

T86.832

Bone graft infection

T86.838

Other complications of bone graft

T86.839

Unspecified complication of bone graft

T86.84

Complications of corneal transplant

T86.840

Corneal transplant rejection

T86.841

Corneal transplant failure

T86.842

Corneal transplant infection

T86.848

Other complications of corneal transplant

T86.849

Unspecified complication of corneal transplant

T86.85

Complication of intestine transplant

T86.850

Intestine transplant rejection

T86.851

Intestine transplant failure

T86.852

Intestine transplant infection

T86.858

Other complications of intestine transplant

T86.859

Unspecified complication of intestine transplant

T86.89

Complications of other transplanted tissue

T86.890

Other transplanted tissue rejection

T86.891

Other transplanted tissue failure

T86.892

Other transplanted tissue infection

T86.898

Other complications of other transplanted tissue

T86.899

Unspecified complication of other transplanted tissue

T86.9

Complication of unspecified transplanted organ and tissue

T86.90

Unspecified complication of unspecified transplanted organ and tissue

T86.91

Unspecified transplanted organ and tissue rejection

T86.92

Unspecified transplanted organ and tissue failure

T86.93

Unspecified transplanted organ and tissue infection

T86.99

Other complications of unspecified transplanted organ and tissue

2. ICD- 9 Code Exceptions

ICD-9 Code

ICD-9 Code Description

042

Human immunodeficiency virus [HIV] disease

203.00

Multiple myeloma, without mention of having achieved remission

283.11

Hemolytic-uremic syndrome

440.1

Atherosclerosis of renal artery

446.20

Hypersensitivity angiitis, unspecified

446.4

Wegener's granulomatosis

572.4

Hepatorenal syndrome

580.89

Acute glomerulonephritis with other specified pathological lesion in kidney

582.9

Chronic glomerulonephritis with unspecified pathological lesion in kidney

592.0

Calculus of kidney

592.9

Urinary calculus, unspecified

593.81

Vascular disorders of kidney

593.89

Other specified disorders of kidney and ureter

599.60

Urinary obstruction, unspecified

646.20

Unspecified renal disease in pregnancy, without mention of hypertension, unspecified as to episode of care or not applicable

710.1

Systemic sclerosis

799.9

Other unknown and unspecified cause of morbidity and mortality

996.81

Complications of transplanted kidney

D. References

  • DI 34001.020 Genitourinary Impairments

  • DI 34005.106 Genitourinary Impairments



DI 24555 TN 04 - Evaluation of Specific Issues - Genitourinary Impairments - 06/18/2018