Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 1.43 $52.83 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 267 268 286.81 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 8 27.07 $1001.65 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 20 20 23.99 $887.80 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 293 299 340.31 $1942.27 $5.71
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 51 56 69.14 $3353.43 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 7.02 $253.29 $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) 3 3 3.00 $163.14 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 56 56.00 $1583.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 210 230 251.02 $15061.12 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 19 24 24.50 $1146.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 111 114 118.87 $14216.65 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 4 15.00 $1875.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 39 40 86.87 $10859.14 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 250 278 309.94 $15497.18 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 61 71 91.64 $4582.15 $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 2 2 3.00 $225.00 $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 36 36 48.86 $2711.57 $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 263 263 370.14 $27760.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 72 74 106.00 $7950.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 85 85 116.03 $8702.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 263 271 403.14 $22374.43 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 244 267 361.00 $27075.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 92 103 151.44 $7344.75 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 546 608 689.83 $33456.76 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 106 117 117.00 $5674.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 472 529 574.96 $27885.37 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 13 13 13.00 $650.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1040 1153 1222.12 $59272.90 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.00 $200.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 11 11 23.14 $1157.15 $50.00
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Subtotal (Total Children Is Unduplicated) 2682 4719 5547.37 $308902.70 $55.68
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 86 110 169.00 $253500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 2.02 $139.25 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 89 94 205.05 $10252.32 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 398 826 1553.88 $77694.18 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 16 19 26.63 $665.84 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1322 1657 3364.01 $168200.44 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 91 96 176.60 $4414.97 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 644 793 1379.87 $68993.26 $50.00
CONOP -CONOP CONSULT, OT, PHONE 34 34 44.45 $1111.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 517 637 1147.86 $57392.75 $50.00
CONPP -CONPP CONSULT, PT, PHONE 37 40 65.80 $1644.94 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1233 1487 2620.84 $131041.98 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 93 101 160.84 $4020.92 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 36 38 96.90 $7114.13 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 16 17 2266.71 $28333.93 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 8.13 $203.34 $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 320 417 2368.68 $59217.05 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 141.14 $7057.15 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 11.02 $551.11 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 24 25 228.57 $11428.58 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 15 15 91.00 $4550.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 8 9 98.96 $2474.05 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3686 4781 36190.11 $1809505.58 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 13.14 $657.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 32 35 167.86 $8392.79 $50.00
INTR -INTR INTERPRETER 83 100 650.49 $32524.45 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1761 2275 14816.79 $1005764.04 $67.88
OCCT -97530HM OT SESSION BY OT ASST 136 153 1080.03 $58666.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2138 2840 17830.63 $1210342.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 165 176 1338.93 $72730.45 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 111 115 380.83 $380.83 $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 9 10 14.00 $7000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 15 15 7.48 $321.63 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 11.00 $2608.32 $237.12
SENS -V5264 EARMOLD 42 45 67.26 $1259.11 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 59 85 310.95 $15547.63 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 7.71 $385.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3362 4340 28435.86 $1930226.47 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 9 9 50.71 $2754.80 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 218 236 1916.23 $25294.23 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 12 15 54.75 $5475.25 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2538 4236 415671.91 $207835.93 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 65.71 $3285.72 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.50 $125.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 68 101 544.15 $27207.52 $50.00
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Subtotal (Total Children Is Unduplicated) 7261 26011 535859.77 $7329987.98 $13.68
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Total 31029 541747.45 $7640832.95 $14.10
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Number of Children (Unduplicated) With at Least One Authorization 7547