Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 1 1 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 24.57 $909.15 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 3.14 $116.29 $37.00
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Subtotal (Total Children Is Unduplicated) 4 5 28.71 $1025.43 $35.71
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 69 70 68.79 $4127.13 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 20 21 21.00 $2511.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 6.00 $750.00 $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 17 17 23.44 $1136.75 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 56 62.43 $3027.79 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 12 12.00 $582.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 36 40.00 $1940.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 130 137 138.00 $6693.00 $48.50
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Subtotal (Total Children Is Unduplicated) 222 362 378.65 $21226.13 $56.06
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 24.13 $1206.66 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 18.57 $928.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 3.23 $80.84 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 97 121 260.69 $13034.35 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 13 24.97 $624.31 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 59 91.06 $4552.90 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 9 15.62 $390.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 27 43.23 $2161.66 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 9 13.43 $335.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 112 201.80 $10089.80 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 15 23.77 $594.17 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.50 $477.23 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 8.00 $400.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 251 310 2565.42 $128270.86 $50.00
INTR -INTR INTERPRETER 23 30 185.12 $9256.09 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 134 155 1464.46 $99407.25 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 15 122.15 $6635.07 $54.32
PHY -97110 PT SESSION BY LICENSED PT 88 110 779.44 $52908.34 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 11 102.71 $5579.29 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $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 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 7 7 12.49 $233.79 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 21.63 $1081.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 175 209 1509.02 $102432.28 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 18 136.68 $1804.16 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 346 581 82608.78 $41304.38 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 60.43 $3021.43 $50.00
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Subtotal (Total Children Is Unduplicated) 454 1849 90308.32 $489463.09 $5.42
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Total 2216 90715.68 $511714.65 $5.64
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Number of Children (Unduplicated) With at Least One Authorization 468