Form CMS-2746-U2 (05/2024) 2
ESRD DEATH NOTIFICATION FORM LIST OF CAUSES
Cardiac
23 Myocardial infarction, acute
25 Pericarditis, incl. cardiac tamponade
26 Atherosclerotic heart disease
27 Cardiomyopathy
28 Cardiac arrhythmia
29 Cardiac arrest, cause unknown
30 Valvular heart disease
31 Pulmonary edema due to exogenous uid
32 Congestive Heart Failure
Vascular
35 Pulmonary embolus
36 Cerebrovascular accident including intracranial
hemorrhage
37 Ischemic brain damage/anoxic encephalopathy
38 Hemorrhage from transplant site
39 Hemorrhage from vascular access
40 Hemorrhage from dialysis circuit
41 Hemorrhage from ruptured vascular aneurysm
42 Hemorrhage from surgery (not 38, 39, or 41)
43 Other hemorrhage (not 38-42, 72)
44 Mesenteric infarction/ischemic bowel
Infection
33 Septicemia due to internal vascular access
34 Septicemia due to vascular access catheter
45 Peritoneal access infectious complication, bacterial
46 Peritoneal access infectious complication, fungal
47 Peritonitis (complication of peritoneal dialysis)
48 Central nervous system infection (brain abscess,
meningitis, encephalitis, etc.)
51 Septicemia due to peripheral vascular disease, gangrene
52 Septicemia, other
61 Cardiac infection (endocarditis)
62 Pulmonary infection (pneumonia, inuenza)
63 Abdominal infection (peritonitis (not comp of PD),
perforated bowel, diverticular disease, gallbladder)
70 Genito-urinary infection (urinary tract infection,
pyelonephritis, renal abscess)
Liver Disease
64 Hepatitis B
71 Hepatitis C
65 Other viral hepatitis
66 Liver-drug toxicity
67 Cirrhosis
68 Polycystic liver disease
69 Liver failure, cause unknown or other
Gastro-Intestinal
72 Gastro-intestinal hemorrhage
73 Pancreatitis
75 Perforation of peptic ulcer
76 Perforation of bowel (not 75)
Metabolic
24 Hyperkalemia
77 Hypokalemia
78 Hypernatremia
79 Hyponatremia
100 Hypoglycemia
101 Hyperglycemia
102 Diabetic coma
95 Acidosis
Endocrine
96 Adrenal insufciency
97 Hypothyroidism
103 Hyperthyroidism
Other
80 Bone marrow depression
81 Cachexia/failure to thrive
82 Malignant disease, patient ever on immunosuppressive
therapy
83 Malignant disease (not 82)
84 Dementia, incl. dialysis dementia, Alzheimer’s
85 Seizures
87 Chronic obstructive lung disease (COPD)
88 Complications of surgery
89 Air embolism
90 Accident related to treatment
91 Accident unrelated to treatment
92 Suicide
93 Drug overdose (street drugs)
94 Drug overdose (not 92 or 93)
98 Other cause of death
99 Unknown
104 Withdrawal from dialysis/uremia
105 COVID-19
106 Severe adverse medication reaction
This report is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). Collection of your Social Security number is authorized by Executive
Order 9397. Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974 (5 U.S.C. 5520;
45 CFR Part 5a). The collection of this information is authorized by Section 226A of the Social Security Act. The information provided will
be used to determine if an individual is entitled to Medicare under the End Stage Renal Disease provisions of the law. The information will
be maintained in system No. 09-700520, “End Stage Renal Disease Program Management and Medical Information System (ESRD PMMIS),”
published in the Federal Register, Vol. 67, No. 116, June 17, 2002, pages 41244-41250 or as updated and republished.
Furnishing the information on this form is voluntary, but failure to do so may result in denial of Medicare benefits. Information from the ESRD
PMMIS may be given to a congressional office in response to an inquiry from the congressional office made at the request of the individual; an
individual or organization for research, demonstration, evaluation, or epidemiologic project related to the prevention of disease or disability,
or the restoration or maintenance of health.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0048 (Expires: 03/31/2027). The time required to
complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical
records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact your ESRD Network.