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
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 43 46 18.27 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 19 23 15.00 $555.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.51 $18.91 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 55 71 34.78 $573.91 $16.50
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 9.71 $350.39 $36.07
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 3 14.00 $1750.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 42.71 $5339.29 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 20 20 20.00 $600.00 $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
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.50 $83.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 11.50 $862.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 49 50 90.29 $4378.86 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 55 58 57.25 $2776.73 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 14 14 14.00 $700.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 171 189 203.00 $9845.50 $48.50
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Subtotal (Total Children Is Unduplicated) 274 374 476.30 $27944.21 $58.67
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 6.00 $300.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 279 309 435.00 $21749.81 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 20 30.57 $764.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 17.25 $862.62 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 8.27 $413.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.57 $64.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 265 294 402.35 $20117.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 19 24.33 $608.34 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 35.43 $2601.17 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 14.86 $371.43 $25.00
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 10.71 $535.72 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 22.43 $560.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 349 390 2324.64 $116232.23 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 38 40 212.71 $14439.04 $67.88
OCCT -97530HM OT SESSION BY OT ASST 19 19 73.64 $4000.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 71 76 431.88 $29315.79 $67.88
PHY -97110HM PT SESSION BY PT ASST 27 28 151.64 $8237.25 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 6 34.99 $1749.52 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 94 101 393.23 $26692.38 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 47 48 250.43 $3305.65 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 366 485 2705.05 $1352.52 $0.50
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Subtotal (Total Children Is Unduplicated) 498 1863 7587.99 $254273.68 $33.51
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Total 2308 8099.07 $282791.80 $34.92
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Number of Children (Unduplicated) With at Least One Authorization 527