Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
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 11 11 11.00 $533.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 33 34 35.09 $2105.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.43 $67.08 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 9.00 $1076.40 $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 25 25 35.86 $1990.07 $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 150 164 221.00 $16575.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 33.43 $1621.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 25.43 $1233.29 $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 21 21 36.71 $1780.64 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 34 34 58.29 $2826.86 $48.50
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Subtotal (Total Children Is Unduplicated) 404 756 1075.20 $69728.20 $64.85
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 32 38.00 $57000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $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 8 10 14.28 $357.09 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 17 23.03 $1151.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 15 16 28.73 $718.33 $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 5 6 6.63 $331.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 11 21.26 $531.39 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 27.36 $1367.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 18 20.96 $523.89 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.86 $485.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 37 406.93 $10173.23 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 19.14 $957.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 436 3151.91 $157595.39 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 13.14 $657.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 8.71 $435.72 $50.00
INTR -INTR INTERPRETER 22 25 214.44 $10721.93 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 87 101 904.56 $61401.40 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 15 158.43 $8605.85 $54.32
PHY -97110 PT SESSION BY LICENSED PT 192 232 2065.13 $140180.73 $67.88
PHY -97110HM PT SESSION BY PT ASST 19 19 158.64 $8617.23 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 284.27 $284.27 $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 3 3 9.29 $464.29 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 7.71 $385.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 485 579 4948.60 $335911.03 $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 22 22 257.43 $3398.06 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 13.14 $1314.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 655 1100 8135.02 $4067.50 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 65.71 $3285.72 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 52.57 $2628.58 $50.00
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Subtotal (Total Children Is Unduplicated) 786 2770 21164.24 $817765.18 $38.64
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Total 3528 22240.44 $887530.38 $39.91
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Number of Children (Unduplicated) With at Least One Authorization 877