Summary Report for FSPSAs Ending During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 1.43 $52.83 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 125 125 126.13 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 13.93 $515.36 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 12 12 13.23 $489.69 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 143 147 155.72 $1057.88 $6.79
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 35 36.00 $1746.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 60 63 63.00 $669.06 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 60 60.00 $529.80 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 59 62 62.00 $669.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 59 59.00 $1285.61 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 56 56.00 $1583.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 118 130 131.15 $7868.95 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 13 14.37 $672.36 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 56 57 60.59 $7246.61 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 22 23 38.57 $4821.44 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 103 106 101.23 $5061.67 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 46 49 61.64 $3082.15 $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 3 3 2.56 $192.08 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 14.86 $1114.28 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 11.27 $845.42 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 15 18.00 $1350.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 29 37.86 $2101.07 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 8.00 $444.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 253 253 358.14 $26860.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 69 71 103.00 $7725.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 78 78 109.03 $8177.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 261 269 399.14 $22152.43 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 229 252 345.50 $25912.50 $75.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 42 42 68.29 $3311.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 264 270 297.98 $14452.23 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 57 57 57.00 $2764.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 220 232 231.00 $11203.56 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 7 7 7.00 $350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 474 493 506.71 $24575.57 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 7 7 7.00 $350.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1632 2829 3337.90 $189751.60 $56.85
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 54 65 114.00 $171000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 37 38 57.91 $2895.32 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 302 473 838.78 $41939.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 10 10 9.73 $243.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 634 696 1261.58 $63079.07 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 42 43 65.78 $1644.40 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 309 338 521.88 $26094.12 $50.00
CONOP -CONOP CONSULT, OT, PHONE 11 11 8.38 $209.58 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 248 261 449.31 $22465.49 $50.00
CONPP -CONPP CONSULT, PT, PHONE 13 13 13.72 $343.06 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 568 621 921.72 $46085.92 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 42 45 63.35 $1583.65 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 15 55.34 $4062.72 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 8 8 900.29 $11253.57 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 2.00 $50.00 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 1.77 $44.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 156 186 936.00 $23400.01 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 99.00 $4950.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 10.00 $500.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 11 71.29 $3564.28 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 13 13 76.86 $3842.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 35.86 $896.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1762 1992 12186.24 $609312.12 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 37.68 $1884.05 $50.00
INTR -INTR INTERPRETER 43 45 264.94 $13247.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 882 994 4922.01 $334105.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 70 73 358.50 $19473.79 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1085 1217 6108.89 $414671.41 $67.88
PHY -97110HM PT SESSION BY PT ASST 72 73 439.69 $23884.12 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 14.97 $14.97 $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 3 3 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 3.16 $135.72 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 16 18 28.93 $541.51 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 33 45 127.44 $6371.91 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 7.71 $385.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1684 1897 9768.62 $663093.91 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.43 $838.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 102 107 643.25 $8490.90 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 8 10 24.47 $2446.67 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1315 1834 135689.92 $67844.96 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.50 $125.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 35 49 174.80 $8739.99 $50.00
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Subtotal (Total Children Is Unduplicated) 3926 11254 177345.67 $2611159.29 $14.72
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Total 14230 180839.29 $2801968.77 $15.49
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Number of Children (Unduplicated) With at Least One Authorization 4529