Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.18 $43.58 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.51 $55.91 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 2.69 $99.49 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 8 46.65 $5830.96 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 3.03 $151.67 $50.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 38 62.50 $4687.50 $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 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 36 38 31.47 $1526.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 45 57.50 $2788.59 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 87 93 76.10 $3690.89 $48.50
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Subtotal (Total Children Is Unduplicated) 155 237 288.25 $19193.22 $66.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
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 8 9 12.14 $607.09 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.60 $40.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 17.97 $898.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.87 $96.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 14 21.74 $1087.08 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.22 $80.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 16 24.42 $1220.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 4 4.95 $123.75 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 6 7 231.43 $2892.86 $12.50
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 3.57 $178.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 26.29 $657.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 347 419 3085.21 $154260.51 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 46.46 $2323.11 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 58 64 523.86 $35559.45 $67.88
OCCT -97530HM OT SESSION BY OT ASST 32 34 248.99 $13525.17 $54.32
PHY -97110 PT SESSION BY LICENSED PT 89 97 974.14 $66124.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 42 47 430.10 $23363.18 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 171 196 1697.32 $115213.93 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 8.86 $481.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 67 72 673.25 $8886.91 $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) 589 1022 8057.00 $431187.11 $53.52
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Total 1262 8347.93 $450479.82 $53.96
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Number of Children (Unduplicated) With at Least One Authorization 602