Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 09
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 243 243 272.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 243 243 272.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.02 $36.87 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.91 $54.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 15 15.00 $727.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 5 5.00 $242.50 $48.50
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Subtotal (Total Children Is Unduplicated) 33 37 35.93 $1974.44 $54.95
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.02 $70.39 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 48.95 $2447.45 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 14.23 $711.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 24 24.80 $1240.01 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 13.00 $650.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 33 38.23 $1911.67 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 19.64 $1442.18 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 2.00 $100.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 10.00 $500.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 12 12 66.71 $3335.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 283 2022.72 $101135.87 $50.00
INTR -INTR INTERPRETER 2 3 5.43 $271.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 288 405 2543.50 $172652.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 21.82 $1185.21 $54.32
PHY -97110 PT SESSION BY LICENSED PT 312 439 2939.07 $199504.28 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 10 3.23 $138.79 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 14 14 17.64 $330.18 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 505 729 4865.12 $330244.05 $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) 748 2025 12670.11 $824450.51 $65.07
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Total 2305 12978.48 $826424.94 $63.68
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Number of Children (Unduplicated) With at Least One Authorization 762