Summary Report for FSPSAs Ending During the Report Period Center: 07
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.18 $43.58 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.18 $43.58 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 4 19.57 $2446.44 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 2.03 $101.67 $50.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 37 61.00 $4575.00 $75.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
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 12 12 10.26 $497.39 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 18 13.24 $642.35 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 38 40 31.60 $1532.60 $48.50
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Subtotal (Total Children Is Unduplicated) 87 121 144.70 $10158.52 $70.20
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.52 $125.84 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.75 $18.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 5.30 $265.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.98 $149.17 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 4 5.08 $254.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.92 $72.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 6 8.92 $445.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.92 $72.92 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 52.29 $653.57 $12.50
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 3.57 $178.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 150 810.13 $40506.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 21 23 160.79 $10914.13 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 34.79 $1889.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 26 27 196.85 $13362.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 14 106.42 $5780.67 $54.32
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 60 493.32 $33486.62 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 31 32 242.71 $3203.83 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.36 $317.86 $50.00
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Subtotal (Total Children Is Unduplicated) 253 342 2139.60 $113198.08 $52.91
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Total 464 2285.49 $123400.18 $53.99
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Number of Children (Unduplicated) With at Least One Authorization 297