Summary Report for FSPSAs Ending During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 07/01/08 and 09/30/08 Date of Report: 11-18-08 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.75 $27.75 $37.00
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Subtotal (Total Children Is Unduplicated) 1 2 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 10.00 $485.00 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 20 20 19.84 $1190.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.43 $67.08 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.00 $717.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 6.75 $337.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 22 23 32.64 $1632.15 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.50 $187.50 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 13.86 $1039.28 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 11.00 $825.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 15 18.00 $1350.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 24 24 31.86 $1768.07 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 2 2 3.00 $166.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 155 155 211.36 $15851.79 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 12.50 $937.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 39 39 62.50 $4687.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 156 160 223.86 $12424.07 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 148 162 219.00 $16425.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 19.29 $935.36 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 9.29 $450.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 19.57 $949.21 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 27 27.00 $1309.50 $48.50
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Subtotal (Total Children Is Unduplicated) 386 715 969.24 $64130.51 $66.17
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 17 22.00 $33000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 35 46.28 $2314.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 5.02 $125.42 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 10.50 $525.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 4.07 $101.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 3.50 $175.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.50 $125.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 3.02 $75.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 20.96 $1047.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 4.66 $116.39 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.86 $485.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 99.21 $2480.36 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 156 162 978.75 $48937.63 $50.00
INTR -INTR INTERPRETER 7 7 108.43 $5421.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 35 36 258.07 $17517.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 49.64 $2696.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 81 89 720.28 $48892.36 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 10 74.57 $4050.72 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 3 5.00 $93.60 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 7.29 $364.29 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 7.71 $385.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 193 207 1371.10 $93070.60 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.57 $248.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 113.29 $1495.37 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 350 493 2581.36 $1290.68 $0.50
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Subtotal (Total Children Is Unduplicated) 439 1135 6547.64 $266281.18 $40.67
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Total 1852 7517.88 $330448.69 $43.96
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Number of Children (Unduplicated) With at Least One Authorization 664