Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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 19 20 8.38 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 5 2.50 $92.50 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 23 27 12.88 $129.50 $10.05
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 18 17.51 $1050.67 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 5.00 $598.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 3 14.00 $1750.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 8.51 $1063.89 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
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
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.00 $150.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 28 57.86 $2806.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 43 45 44.25 $2146.23 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 119 128 128.02 $6208.77 $48.50
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Subtotal (Total Children Is Unduplicated) 189 249 286.48 $16266.26 $56.78
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 220 257 526.39 $26319.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 50 53 109.01 $2725.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 26.24 $1312.15 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 24.10 $1205.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.07 $101.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 238 282 564.97 $28248.49 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 33 37 64.13 $1603.34 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 11 31.33 $2299.98 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 293.00 $3662.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 34.43 $860.71 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 13.14 $657.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 333 410 3404.36 $170218.11 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 19 20 124.71 $8465.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 24 28 132.64 $7204.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 57 59 384.28 $26084.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 36 36 214.57 $11655.51 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 15 104.92 $5245.95 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 62 261.79 $17769.99 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 14.14 $768.24 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 32 34 170.21 $2246.82 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 13.14 $1314.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 344 565 4153.95 $2076.97 $0.50
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Subtotal (Total Children Is Unduplicated) 429 1907 10673.53 $322247.23 $30.19
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Total 2183 10972.90 $338642.99 $30.86
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Number of Children (Unduplicated) With at Least One Authorization 436