Summary Report for FSPSAs Initiated During the Report Period Center: 54
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 1 1 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.00 $37.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 3.14 $116.29 $37.00
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Subtotal (Total Children Is Unduplicated) 2 3 5.14 $153.29 $29.81
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 34 34 33.42 $2005.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.00 $1076.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.87 $430.04 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 28 28.00 $1358.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 18.00 $873.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 62 64 64.00 $3104.00 $48.50
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Subtotal (Total Children Is Unduplicated) 117 173 177.29 $9964.56 $56.21
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.86 $92.86 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 3.90 $195.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 53 59 89.05 $4452.51 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 2.50 $62.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 22 25.62 $1280.84 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 13.08 $654.16 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.78 $19.58 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 43 46 59.32 $2966.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 4 5.80 $145.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 114 125 800.52 $40025.93 $50.00
INTR -INTR INTERPRETER 16 19 107.39 $5369.65 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 47 51 396.12 $26888.39 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 31.14 $1691.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 33 34 197.83 $13428.61 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 9.18 $498.58 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 0.27 $4.99 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 5.53 $276.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 77 85 494.91 $33594.61 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 59.43 $784.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 176 253 19724.25 $9862.12 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 19.00 $950.00 $50.00
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Subtotal (Total Children Is Unduplicated) 228 743 22051.48 $144246.20 $6.54
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Total 919 22233.91 $154364.05 $6.94
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Number of Children (Unduplicated) With at Least One Authorization 249