Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 9.17 $339.17 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 9.17 $339.17 $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 10 10 8.86 $531.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.96 $114.29 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 14.64 $732.14 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 5.00 $375.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 7.00 $525.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.00 $225.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 6 9.00 $499.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 24.14 $1170.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.00 $582.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 34 34 56.43 $2736.78 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 9 9 9.00 $450.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 79 116 172.03 $9558.04 $55.56
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 17.58 $879.05 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 129 156 335.46 $16772.91 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 82 135.48 $6773.82 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.27 $56.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 85 141.37 $7068.30 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 9.87 $246.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 90 118.12 $5906.16 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 10.71 $786.64 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 179.00 $4475.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 112.00 $5600.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 211 2010.54 $100527.12 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 5.71 $285.48 $50.00
INTR -INTR INTERPRETER 1 1 4.00 $200.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 123 145 1428.77 $96985.23 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 99.72 $5416.73 $54.32
PHY -97110 PT SESSION BY LICENSED PT 115 150 1463.07 $99312.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 10 101.85 $5532.62 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5264 EARMOLD 1 1 0.96 $17.89 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 13.22 $661.19 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 166 202 1840.15 $124909.13 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 28.71 $379.03 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 37 55 21697.64 $10848.82 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.50 $125.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 25.43 $1271.67 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 328 1236 29804.42 $495521.11 $16.63
-----------------------------------------------------------------------------------------------------------------------------
Total 1356 29985.61 $505418.32 $16.86
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 337