Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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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 14 14 14.00 $700.00 $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 24 25 36.00 $2700.00 $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 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 8 8.00 $388.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.00 $200.00 $100.00
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Subtotal (Total Children Is Unduplicated) 98 203 293.60 $19069.28 $64.95
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.23 $61.67 $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 2 2 3.30 $82.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 17.69 $884.65 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 7.00 $175.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 25.94 $1297.15 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 8 9.32 $232.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.42 $20.84 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 17 36.99 $1849.66 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 12.12 $302.92 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 1703.43 $21292.86 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 108 832.42 $41620.98 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 10.43 $521.43 $50.00
INTR -INTR INTERPRETER 3 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 40 50 341.03 $23149.38 $67.88
OCCT -97530HM OT SESSION BY OT ASST 18 20 131.15 $7124.27 $54.32
PHY -97110 PT SESSION BY LICENSED PT 28 36 304.28 $20654.28 $67.88
PHY -97110HM PT SESSION BY PT ASST 15 17 79.88 $4339.15 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 68 623.57 $42328.01 $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 24 26 200.82 $2650.88 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 15.00 $1500.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 26.04 $1302.15 $50.00
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Subtotal (Total Children Is Unduplicated) 205 414 4410.22 $177003.89 $40.13
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Total 618 4704.82 $196073.17 $41.67
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Number of Children (Unduplicated) With at Least One Authorization 228