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Each infusion encounter record should include: Diagnosis and disease severity: Current disease activity score (e.g., Mayo score for UC, Harvey-Bradshaw index for Crohn’s) documented at the time of infusion authorization Prior therapy failure: Record of conventional therapies tried and failed, with dates and outcomes, to support step-therapy PA criteria Infusion details: Drug name, dose in mg, route of administration, infusion start and stop time, rate, and lot number NDC number: The 11-digit NDC of the specific vial administered, required for commercial and Medicaid claims Supervising provider: Name and NPI of the provider overseeing the infusion, required for Part B claims Adverse event monitoring: Vital signs pre-, during, and post-infusion, and documentation of any reactions Practices should keep a standardized infusion record template in the patient chart
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Since he seemed initially to benefit from this treatment, it is still possible that he was deficient
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