Summary Report for FSPSAs Initiated During the Report Period Center: 03
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 2 2 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 21.50 $1612.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 21 37.50 $2812.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 57.00 $3163.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.00 $300.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 24 26 38.57 $1870.71 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 18.00 $873.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 33 35 35.00 $1697.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 21.00 $1018.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 98 103 103.00 $4995.50 $48.50
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Subtotal (Total Children Is Unduplicated) 159 274 343.57 $18904.71 $55.02
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.07 $3.29 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 62 67 92.00 $4600.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 91 100 186.91 $9345.74 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 25 36.83 $1841.68 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 24 48.75 $2437.43 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 82 146.14 $7307.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 126 139 960.96 $48048.12 $50.00
INTR -INTR INTERPRETER 4 5 12.86 $642.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 41 43 267.79 $18177.29 $67.88
PHY -97110 PT SESSION BY LICENSED PT 52 56 397.57 $26986.82 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 1.71 $1.71 $1.00
SENS -V5264 EARMOLD 2 2 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 103 108 673.37 $45708.02 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.57 $328.57 $50.00
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Subtotal (Total Children Is Unduplicated) 225 658 2837.52 $165553.40 $58.34
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Total 934 3184.09 $184458.12 $57.93
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Number of Children (Unduplicated) With at Least One Authorization 234