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
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
--------------------------------------------------------------------
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 -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 11.41 $684.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 12 13 69.15 $8643.46 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 9.03 $451.67 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.50 $83.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 86 113 180.21 $13516.07 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 15 15 13.81 $669.84 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 84 88 90.36 $4382.39 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 18 19 17.31 $839.32 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 79 85 94.44 $4580.39 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 262 280 253.55 $12297.41 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 430 650 763.78 $47861.64 $62.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 18.63 $931.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 8.33 $416.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 6.48 $162.08 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 14 17.96 $897.92 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 1.97 $49.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 34.87 $1743.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 7 7.72 $192.91 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 21 31.67 $1583.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 9.12 $227.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 29 33 44.68 $2233.75 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 9 7.92 $197.92 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 9 11 319.14 $3989.29 $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 570 694 5156.29 $257814.57 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 67.18 $3358.82 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 152 174 1403.94 $95299.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 51 54 421.85 $22914.77 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 194 1769.83 $120135.76 $67.88
PHY -97110HM PT SESSION BY PT ASST 72 79 704.41 $38263.45 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 20.14 $20.14 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 4.00 $172.00 $43.00
SENS -V5264 EARMOLD 3 3 7.56 $141.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 469 568 4957.00 $336481.42 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 38.29 $2079.68 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 147 161 1449.35 $19131.48 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 36.30 $1815.24 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1133 2111 16583.47 $920740.10 $55.52
-----------------------------------------------------------------------------------------------------------------------------
Total 2764 17349.94 $968701.23 $55.83
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1164