HCPCS M1265: CMS Medical Evidence Form 2728, Initial Completion - OpenPayer

Summary & Overview

HCPCS M1265: CMS Medical Evidence Form 2728, Initial Completion

HCPCS Level II code M1265 denotes the initial completion of the CMS Medical Evidence Form 2728 for patients starting dialysis. The form establishes ESRD status, captures baseline clinical and demographic data, and supports Medicare entitlement and dialysis program enrollment. Nationally, accurate and timely completion of Form 2728 is essential for patient care coordination, program reporting, and payer enrollment processes.

Key payers covered in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code's clinical and administrative role, guidance on typical sites of service, and an outline of where this code fits in billing and reporting workflows. The publication highlights common payer recognition and billing contexts, and notes available data elements where present. Data not available in the input will be noted explicitly.

This analysis provides benchmarks and policy-relevant context for clinicians, billing professionals, and administrators who manage dialysis intake processes and payer submissions. It clarifies the purpose of M1265, situates it within ESRD patient registration, and summarizes what organizations should document when reporting the initial Form 2728 completion.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1265HCPCS Level IIESRDForm 2728dialysismedical documentationoutpatient dialysisadministrative billing

Billing Code Overview

HCPCS Level II code M1265 represents completion of the CMS Medical Evidence Form 2728 for dialysis patients, specifically indicating the initial form completed. This code documents the formal registration and baseline clinical information for patients with end-stage renal disease (ESRD) initiating dialysis.

Service type: Administrative documentation and patient registration related to dialysis care
Typical site of service: Dialysis center or outpatient dialysis facility

Clinical & Coding Specifications

Clinical Context

A patient with end-stage renal disease (ESRD) presents to an outpatient dialysis center for initiation of maintenance dialysis. The dialysis clinic clinician or designated staff completes the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Form 2728 (initial form completed), documented and transmitted to CMS to register the patient for ESRD benefits and track dialysis start date, modality, comorbidities, and vascular access. Typical workflow: upon decision to initiate dialysis (in-center hemodialysis, home hemodialysis, or peritoneal dialysis), the nephrology provider obtains the patient’s demographic data, primary and secondary diagnoses, start date of dialysis, cause of ESRD, initial dialysis modality, vascular access type, and transplant candidacy status. The provider signs the completed CMS-2728 and the dialysis facility uploads or transmits the form to the ESRD Network and Medicare. Typical site of service is an outpatient dialysis facility (end-stage renal disease dialysis center) or hospital renal unit when the initial dialysis start occurs inpatient and the form is completed at discharge for registry purposes. Common patient scenario: a 62-year-old with progressive chronic kidney disease due to diabetic nephropathy who requires initiation of thrice-weekly in-center hemodialysis via a tunneled central venous catheter while awaiting maturation of an arteriovenous fistula; the nephrologist completes the initial CMS-2728 to document ESRD start, access type, comorbid conditions, and expected modality.

Coding Specifications

Modifier	Description	When to Use

HCPCS Level II M1362: Patients Who Died During the Measurement Period

HCPCS-M1332-INADEQUATE-INITIAL-EVALUATION-FOLLOW-UP

HCPCS M1332: Inadequate Initial Evaluation or Missed 2-Week Re-evaluation

HCPCS-M1151-HEART-TRANSPLANT-LVAD-STATUS

HCPCS M1151: Heart Transplant Status or LVAD Support

HCPCS-M1231-HCV-ANTIBODY-TEST-NONREACTIVE

HCPCS M1231: HCV Antibody Test, Nonreactive

HCPCS-M1286-BMI-OUTSIDE-NORMAL-PARAMETERS-FOLLOW-UP-NOT-COMPLETED-MEDICAL-REASON

HCPCS Level II M1286: BMI Outside Normal Parameters, Follow-Up Not Completed

HCPCS-M1430-RETINAL-EXAM-NO-RETINOPATHY-BOTH-EYES-SEVERITY-DOCUMENTED

HCPCS M1430: Retinal Exam, No Retinopathy in Both Eyes with Severity Documented

HCPCS-M1266-SNF-ADMISSION

HCPCS M1266: Skilled Nursing Facility Admission

HCPCS-M1147-ONGOING-CARE-DISCONTINUED-DUE-TO-HOSPITALIZATION-OR-SURGERY

HCPCS M1147: Ongoing Care Discontinued Due to Hospitalization or Surgery

HCPCS-M1254-PATIENT-DECEASED-ON-HOME-HEALTH-SURVEY-CONTACT

HCPCS Level II M1254: Patient Deceased on Home Health Survey Contact

HCPCS-M1398-PROMIS-BASELINE-FOLLOW-UP-SURVEYS

HCPCS Level II M1398: PROMIS Baseline and Follow-up Survey Documentation

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`22`	Increased procedural services	When documenting substantially greater work for preparation/completion of the `CMS-2728` beyond usual effort (rare for form completion).
`23`	Unusual anesthesia	Not typically applicable to form completion; included for completeness.
`52`	Reduced services	When the form is partially completed due to transfer of care and another provider completes remaining sections.
`53`	Discontinued procedure	When initiation of dialysis is planned but aborted before CMS-2728 completion (rare).
`54`	Surgical care only	Not typically applicable; used if procedural surgical responsibility is transferred and documentation of perioperative dialysis initiation is limited.
`55`	Postoperative management only	Not typically applicable; use only if postoperative care provider completes the form elements relevant to dialysis start.
`56`	Preoperative management only	Not typically applicable; use if only pre-procedure provider documents initial ESRD data.
`62`	Two surgeons	Rarely applicable; use if two practitioners of equal specialty share responsibility for documented initiation details.
`AS`	Accredited resident at site of service	Use when a resident in an accredited training program completes the form under appropriate supervision.
`CO`	Worker’s compensation	Use when services relate to a worker’s compensation claim affecting ESRD initiation documentation.
`CQ`	Service furnished under a federal health care program beneficiary	Use when a federally-employed beneficiary (for example, Department of Veterans Affairs) has the form completed under special billing rules.
`FX`	Split/shared E/M — primary practitioner	Use when the physician documents and is the primary practitioner for the encounter that generated the `CMS-2728`.
`FY`	Split/shared E/M — non-physician practitioner	Use when an advanced practice provider documents the encounter and is billing under split/shared rules.
`QK`	Medical direction of two, three, or four assistants	Not typically applicable to form completion; included for completeness.
`QX`	Certified registered nurse anesthetist (CRNA) service with medical direction	Not applicable to form completion; included for completeness.

Taxonomy Code	Specialty	Notes
`2080P0207X`	Nephrology	Primary specialty completing `CMS-2728` to document ESRD initiation.
`208200000X`	Internal Medicine	Hospitalist or internist may complete the form if initiating dialysis in inpatient setting.
`363L00000X`	Dialysis Facility Provider	Medical director or designated facility clinician completing registry documentation.
`2084N0400X`	Nurse Practitioner	Advanced practice providers often gather data and sign the form per state scope of practice.
`2084P0800X`	Physician Assistant	PAs frequently participate in dialysis initiation documentation under supervising physician.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N18.6`	End stage renal disease	Primary diagnosis indicating ESRD; directly necessitates completion of `CMS-2728`.
`N18.5`	Chronic kidney disease, stage 5	Often the immediate precursor to ESRD and dialysis initiation; used when documenting cause and progression.
`E11.22`	Type 2 diabetes mellitus with diabetic chronic kidney disease	Common underlying etiology for ESRD documented on the `CMS-2728`.
`I12.0`	Hypertensive chronic kidney disease with stage 5 chronic kidney disease or ESRD	Hypertension-related kidney disease frequently listed as cause of ESRD on the form.
`Z99.2`	Dependence on renal dialysis	Used to indicate ongoing dialysis dependence after initiation; relevant to registry and benefits tracking.
`T82.121A`	Infection and inflammatory reaction due to kidney dialysis catheter, initial encounter	Represents complications related to vascular access that may be documented on follow-up forms after initial `CMS-2728`.
`Z94.0`	Kidney transplant status	Relevant for documenting transplant candidacy or prior transplant history on the `CMS-2728`.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99221`	Initial hospital care, typically 30 minutes	Used when ESRD initiation and `CMS-2728` completion occur during an inpatient admission and the physician documents the initial hospital encounter.
`99238`	Hospital discharge day management	Used when the patient is discharged after initiation of dialysis and the discharge summary includes completion of the `CMS-2728` documentation.
`90935`	Hemodialysis procedure with single evaluation by a physician per week	Represents the dialysis treatment service that begins after `CMS-2728` documentation of dialysis start; commonly performed in-center.
`90945`	Hemodialysis procedure for home dialysis training	Related when the `CMS-2728` documents initiation of home hemodialysis and training services are scheduled.
`49422`	Placement of peritoneal dialysis catheter (percutaneous)	Performed when `CMS-2728` indicates modality as peritoneal dialysis and a catheter placement is part of initiation workflow.
`36818`	Insertion of tunneled central venous dialysis catheter	Performed when initial access at dialysis start is a tunneled central venous catheter; procedure commonly precedes or coincides with completion of `CMS-2728`.

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