DI 24555: Evaluation of Specific Issues - Genitourinary Impairments

Effective Dates: 06/15/2018 - Present

TN 4 (06-18)

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

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