Summary Report for FSPSAs Initiated During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 8 8 8.00 $388.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 23 23 22.18 $1330.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 6.75 $337.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 23 24 33.64 $1682.15 $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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 11.29 $547.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 15.57 $755.21 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 15 15.00 $727.50 $48.50
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Subtotal (Total Children Is Unduplicated) 361 696 932.86 $62234.37 $66.71
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 25 29.00 $43500.00 $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 29 29 37.00 $1850.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 7 5.38 $134.58 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 8 9.47 $473.33 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 10 19.60 $490.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.50 $25.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 4.63 $231.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 11.10 $277.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 11.87 $593.45 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 12.63 $315.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 104.00 $2600.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 19.14 $957.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 188 1074.79 $53739.28 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 8.71 $435.72 $50.00
INTR -INTR INTERPRETER 15 15 77.72 $3886.20 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 34 36 245.35 $16654.53 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 17.29 $938.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 88 96 653.73 $44375.44 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 15.29 $830.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 6.22 $6.22 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 3 4 7.00 $131.04 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 239 255 1660.64 $112724.47 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 71.86 $948.51 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 367 556 2847.38 $1423.69 $0.50
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Subtotal (Total Children Is Unduplicated) 458 1305 6958.31 $288861.74 $41.51
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Total 2003 7892.17 $351133.11 $44.49
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Number of Children (Unduplicated) With at Least One Authorization 561