TransplantCheck

Dialysis teams

Transplant referral and tracking: what federal rules ask of dialysis facilities

What do the ESRD Conditions for Coverage require for transplant referral?

Federal rules require the dialysis team to assess suitability for transplant referral using criteria set by the prospective transplant center and its surgeons.1

ESRD means end-stage renal disease, or kidney failure. These are facility rules. Read the full regulation for all duties.

When must the dialysis team assess and reassess each patient?

As of October 2026, the initial assessment is due within the later of 30 calendar days or 13 outpatient hemodialysis sessions, starting with the first outpatient session.1

As of October 2026, reassess within three months after the initial assessment. Reassess stable patients at least annually and unstable patients at least monthly.1

What must a dialysis facility document when a patient isn't referred for a transplant?

If a patient is not suitable for referral, federal rules require the basis for nonreferral in the medical record.1

The plan of care must document the patient’s decision to pursue or decline transplant referral, or the reasons for nonreferral.2

What must the dialysis team do while a patient is on the transplant waiting list?

Federal rules require the facility to track each center referral, monitor waiting-list status and communicate with the center at least annually and when status changes.2

What should my dialysis unit do while I wait for a kidney transplant? (Waiting list)

Which payment year 2027 measures involve depression screening or transplant waitlisting?

As of October 2026, payment year 2027 includes the Percentage of Prevalent Patients Waitlisted and Clinical Depression Screening and Follow-Up measures.3

As of October 2026, calendar year 2025 is the performance period for payment year 2027.3

As of October 2026, the waitlisting measure counts patient-months on a kidney or kidney-pancreas list at month’s end, among eligible patients under age 75.4

The waitlisting measure excludes patients aged 75 or older, months with a skilled nursing facility or hospice admission, and patients with a prior skilled nursing facility admission recorded on the medical evidence form.4

As of October 2026, the depression measure counts reported conditions 1, 2, 4 or 5; conditions 3 and 6 do not count in its numerator.4

A positive screen with a follow-up plan counts; a positive screen without a plan needs a documented reason that the patient is not eligible.4

A negative screen counts, as does no screen with a documented reason that the patient is not eligible; no screen with no reason does not count.4

Use the full specifications for all exclusions. QIP means Quality Incentive Program. Keep payment measures, facility rules and survey guidance separate when you check your work.

What changes in the CY 2027 ESRD PPS final rule?

As of October 2026, the final rule changes quality measures starting in payment year 2029, including replacing the high-calcium reporting measure with a high-phosphorus clinical measure.5

The CY 2027 final rule was published on October 30, 2026; its regulations take effect January 1, 2027.6

CMS discusses a possible future measure about patient life goals; the final rule does not adopt that measure.5

CY means calendar year. PPS means Prospective Payment System. Read the full source below for all changes.

Who helps with a dispute between a patient and a dialysis facility?

ESRD Networks help resolve concerns about care, including disputes between patients and facility staff.7

As of October 2026, Quality Insights serves Network 2 in New York and Network 3 in New Jersey, Puerto Rico and the U.S. Virgin Islands.8

IPRO’s Network 1 serves Connecticut and the other New England states.9

How can a dialysis care team hear from patients between visits?

Invite patients to write in their own words and ask what they want to share. TransplantCheck is a place for shared check-ins and journal entries.

Use the home page to see the share switch and clinic review mark. Ask us about a pilot for your unit.

Questions to bring to your team

  • Where is the referral decision recorded?
  • Who confirms the center received the referral?
  • When is the next reassessment due?
  • Who checks waiting-list status?
  • How do we record patient goals?
  • Which source and payment year are we using?
Sources
  1. eCFR. § 494.80 Condition: Patient assessment. 494.80(a)(10). 494.80(b)(1). 494.80(b)(2), (d). Checked October 30, 2026.
  2. eCFR. § 494.90 Condition: Patient plan of care. 494.90(a)(7)(ii)(A–C). 494.90(c)(1–3). Checked October 30, 2026.
  3. CMS. Payment Year 2027 ESRD QIP Fact Sheet. Care Coordination, pages 2–3. Page 1. Checked October 30, 2026.
  4. CMS. Calendar Year (CY) 2025 Measure Technical Specifications. PPPW numerator and denominator, page 30. PPPW exclusions, page 30. Clinical Depression Screening and Follow-Up, page 35. Conditions 1–3, pages 34–35. Conditions 4–6, page 35. Checked October 30, 2026.
  5. CMS. Calendar Year (CY) 2027 End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule — CMS-1846-F. ESRD QIP changes. D-PaLS discussion. Checked October 30, 2026.
  6. Federal Register / CMS. Medicare Program; CY 2027 Changes to the End-Stage Renal Disease (ESRD) Prospective Payment System, Acute Kidney Injury (AKI) Dialysis Payment, and ESRD Quality Incentive Program. Dates, printed page 68736. Checked October 30, 2026.
  7. Quality Insights. Patient Grievances. What the Network Can Do. Checked October 30, 2026.
  8. Quality Insights. ESRD Networks. Who We Serve. Checked October 30, 2026.
  9. IPRO. About the Network of New England. Network service area. Checked October 30, 2026.
Page facts

Written by the TransplantCheck team.

Facts checked against official sources on October 30, 2026.

Changes

  • October 30, 2026: first version.
  • November 2, 2026: new site layout.