Summary Report for FSPSAs Initiated During the Report Period Statewide
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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 25 26 15.38 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 6 3.50 $129.50 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 10.03 $371.16 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 36 42 30.16 $509.91 $16.90
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 27 27.00 $1309.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 60 63 63.00 $669.06 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 58 61 61.00 $538.63 $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) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 56 56.00 $1583.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 105 110 122.18 $7331.05 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 17 16.13 $755.04 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 50 50 53.28 $6372.04 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 3 14.00 $1750.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 17 17 41.08 $5134.53 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 76 79 92.54 $4627.06 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 52 62 80.64 $4032.15 $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 -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 16.86 $1264.28 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $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 31 31 39.86 $2212.07 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 10 10 11.00 $610.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 255 255 362.14 $27160.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 67 69 101.00 $7575.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 76 76 107.03 $8027.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 259 267 399.14 $22152.43 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 231 254 347.00 $26025.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 47 49 62.44 $3028.25 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 271 297 339.19 $16450.51 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 58 60 60.00 $2910.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 228 251 251.88 $12216.40 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 10 10 10.00 $500.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 541 575 585.62 $28402.79 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1615 2919 3482.86 $197477.89 $56.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 49 61 96.00 $144000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 34 35 62.45 $3122.64 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 271 462 827.17 $41358.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 12 12.70 $317.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 622 673 1086.36 $54318.02 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 29 30 45.12 $1127.91 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 297 314 436.54 $21826.82 $50.00
CONOP -CONOP CONSULT, OT, PHONE 15 15 17.45 $436.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 251 259 416.63 $20831.68 $50.00
CONPP -CONPP CONSULT, PT, PHONE 14 14 21.71 $542.71 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 567 618 891.16 $44557.89 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 40 42 52.77 $1319.35 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 15 21.14 $1552.20 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 1207.71 $15096.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 172 203 1163.92 $29097.91 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 42.14 $2107.15 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 7 52.14 $2607.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.29 $307.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1806 2073 11886.30 $594314.93 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 25 27 93.38 $4668.97 $50.00
INTR -INTR INTERPRETER 53 57 253.05 $12652.28 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 841 957 4679.43 $317639.46 $67.88
OCCT -97530HM OT SESSION BY OT ASST 47 48 291.01 $15807.63 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1044 1199 5843.58 $396662.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 48 50 300.03 $16297.36 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 61 61 53.36 $53.36 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 11.00 $5500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 1.32 $56.55 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 22 23 30.91 $578.66 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 32 40 125.30 $6264.90 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1675 1937 9933.48 $674284.63 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 21.14 $1148.48 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 83 84 631.82 $8339.98 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 6 9.13 $913.34 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1295 1839 139040.38 $69520.19 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 35 47 187.96 $9397.81 $50.00
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Subtotal (Total Children Is Unduplicated) 3954 11239 179865.96 $2520356.61 $14.01
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Total 14200 183378.98 $2718344.42 $14.82
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Number of Children (Unduplicated) With at Least One Authorization 4254