Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 19 20 8.38 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 5 2.50 $92.50 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 22 26 11.88 $92.50 $7.78
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 2 13.00 $1625.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 3 3 3.00 $90.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.06 $4.58 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.27 $20.42 $75.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.00 $150.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 15 44.86 $2175.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 19 18.25 $885.23 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 52 55 55.00 $2667.50 $48.50
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Subtotal (Total Children Is Unduplicated) 80 104 142.44 $8193.56 $57.52
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 109 122 170.00 $8500.02 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 9 13.03 $325.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 3.60 $180.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 6.37 $318.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 111 155.27 $7763.35 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 12.87 $321.67 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 11.00 $807.62 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 132 149 912.43 $45621.45 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 9 10 74.07 $5027.97 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 17.14 $931.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 27 27 215.92 $14656.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 45.50 $2471.55 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 6 34.99 $1749.52 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 26 101.50 $6889.83 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 56.50 $745.80 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 134 176 1116.91 $558.45 $0.50
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Subtotal (Total Children Is Unduplicated) 177 676 2949.10 $96969.52 $32.88
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Total 806 3103.42 $105255.58 $33.92
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Number of Children (Unduplicated) With at Least One Authorization 186