Summary Report for FSPSAs Initiated During the Report Period Center: 02
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 12 12 12.00 $600.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 53 53 88.29 $6621.43 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 24 35.00 $2625.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 17.53 $1315.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 64 67 105.29 $5843.36 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 7.50 $562.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.00 $242.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 90 193 283.60 $18503.28 $65.24
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.86 $92.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.30 $57.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 3.55 $177.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 4.00 $100.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 3.25 $81.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 6.88 $344.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 6.05 $151.25 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 1186.29 $14828.57 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 45 45 287.50 $14374.98 $50.00
INTR -INTR INTERPRETER 2 2 5.00 $250.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 17 18 98.44 $6682.30 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 35.36 $1920.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 12 14 104.29 $7078.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 4 21.89 $1189.22 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 31 218.36 $14822.05 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.29 $667.36 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 35.14 $463.88 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 12.90 $645.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 112 170 2055.34 $67205.39 $32.70
-----------------------------------------------------------------------------------------------------------------------------
Total 364 2339.94 $85708.68 $36.63
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 143