Summary Report for FSPSAs Ending During the Report Period Center: 09
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 113 113 118.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 113 113 118.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.00 $111.00 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 4 4.00 $194.00 $48.50
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Subtotal (Total Children Is Unduplicated) 19 21 21.00 $1035.50 $49.31
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 7.21 $360.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.47 $123.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 5.47 $273.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 12.50 $917.75 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 10.00 $500.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 11 11 65.71 $3285.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 103 114 592.57 $29628.35 $50.00
INTR -INTR INTERPRETER 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 149 175 811.54 $55087.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.14 $333.68 $54.32
PHY -97110 PT SESSION BY LICENSED PT 166 189 990.03 $67203.37 $67.88
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.16 $49.72 $43.00
SENS -V5264 EARMOLD 2 2 4.56 $85.37 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 285 336 1737.08 $117913.28 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
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Subtotal (Total Children Is Unduplicated) 426 854 4256.44 $280616.16 $65.93
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Total 988 4395.59 $281651.66 $64.08
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Number of Children (Unduplicated) With at Least One Authorization 437