Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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 3 3 4.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 3 3 4.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
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 45 56 68.57 $3325.71 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 52 52.00 $2522.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 67 78 78.00 $3783.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 53 53 53.00 $2570.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 183 215 215.00 $10427.50 $48.50
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Subtotal (Total Children Is Unduplicated) 281 526 595.57 $31197.81 $52.38
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 64 69 94.00 $4700.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 152 181 424.41 $21220.40 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 64 147.44 $7371.82 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 53 59 133.81 $6690.71 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 148 174 358.44 $17921.79 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 227 274 2095.21 $104760.38 $50.00
INTR -INTR INTERPRETER 8 11 74.36 $3717.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 87 107 826.69 $56115.57 $67.88
PHY -97110 PT SESSION BY LICENSED PT 108 131 1047.74 $71120.82 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 4.78 $4.78 $1.00
SENS -V5264 EARMOLD 2 2 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 184 220 1579.21 $107196.72 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 33.47 $1673.73 $50.00
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Subtotal (Total Children Is Unduplicated) 393 1306 6825.62 $402622.73 $58.99
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Total 1835 7425.19 $433820.54 $58.43
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Number of Children (Unduplicated) With at Least One Authorization 401