CMS SOM App. H, Tag V554

address, but not be limited to, the following: (7) Modality. (ii) Transplantation status.

When the patient is a transplant referral candidate, the interdisciplinary team must

develop plans for pursuing transplantation. The patient’s plan of care must include

documentation of the–

(A) Plan for transplantation, if the patient accepts the transplantation referral;

(B) Patient’s decision, if the patient is a transplantation referral candidate but declines the

transplantation referral; or

(C) Reason(s) for the patient’s nonreferral as a transplantation candidate as documented in

accordance with § 494.80(a)(10).

Interpretive Guidance § 494.90(a)(7)(ii)

The patient’s plan of care must reflect the information from the IDT’s evaluation of the patient's

suitability for transplantation referral, as required under Condition V513 for patient assessment.

In accordance with the requirements at § 494.70(a)(7): Patients’ rights, the dialysis facility must

inform each dialysis patient about all treatment modalities and settings when they begin their

treatment. This includes discussions about transplantation. The patient record must show

evidence that the patient was informed about transplantation as an option. Discussions about

organ transplantation should include information on living and deceased kidney donation,

Medicare-approved transplant program(s) in the geographical area, and each transplant

facility’s selection criteria. Each patient’s record must reflect the IDT’s determination regarding

the patient’s suitability and whether the patient accepted or declined referral for transplantation,

along with the reason for non-referral.

If a patient is determined to be suitable for transplantation referral, the IDT must document the

referral and provide applicable information to the transplant program as appropriate or when

requested.

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Documentation in patient records should agree with the patient’s understanding of their status

as a transplant candidate. Patients may contact a transplant program directly to schedule an

appointment for more information and evaluation. If this is the case, the IDT should be aware of

the self-referral. A patient’s insurance coverage and a transplant program’s selection criteria

may dictate which transplant program(s) the patient can access.