Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 0.29 $10.57 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 14.57 $539.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 0.82 $30.39 $37.00
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Subtotal (Total Children Is Unduplicated) 4 6 15.68 $580.10 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 34 35.00 $1697.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 48 50 56.08 $3364.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 5.29 $247.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 19 26.00 $3109.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 16 17 20.00 $1000.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 71 72 100.68 $5033.93 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 10 10 14.50 $1087.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.50 $83.25 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 47 47 61.91 $4643.34 $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 10 10 17.00 $1275.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 57 59 76.00 $5700.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 97 101 134.91 $7487.57 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 545 550 753.57 $56517.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 36 36 41.50 $3112.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 127 128 205.14 $15385.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 607 616 846.07 $46956.97 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 654 704 963.00 $72225.01 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 19 104.00 $5044.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 53 56 89.71 $4351.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 31 33 40.14 $1946.93 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 57 59 90.14 $4371.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 150 158 229.88 $11149.23 $48.50
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Subtotal (Total Children Is Unduplicated) 1344 2790 3920.03 $256232.98 $65.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 52 81 90.00 $135000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 16 17 23.97 $1198.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 119 126 156.46 $7822.98 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 20 25 53.97 $1349.28 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 31 59.83 $2991.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 20 23 110.23 $2755.71 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 5.67 $283.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 13 20.07 $1003.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 13 16 48.46 $1211.49 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 40 88.85 $4442.49 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 39 42 97.55 $2438.84 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 105.71 $1321.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 52 65 1248.36 $31208.93 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 62.00 $3100.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 549 713 10539.29 $526964.42 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 30.71 $1535.72 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 21.86 $1092.86 $50.00
INTR -INTR INTERPRETER 44 56 888.40 $44419.89 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 142 187 3096.61 $210197.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 25 26 482.21 $26193.63 $54.32
PHY -97110 PT SESSION BY LICENSED PT 252 363 6280.79 $426340.16 $67.88
PHY -97110HM PT SESSION BY PT ASST 31 31 547.10 $29718.22 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 55 959.18 $959.18 $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 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 6 10 16.28 $304.80 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 46.29 $2314.29 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 22.29 $1114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 678 963 15354.06 $1042233.72 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 75.71 $4112.80 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 58 60 950.57 $12547.54 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 30.14 $3014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1032 2129 26059.03 $13029.51 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 7 125.57 $6278.57 $50.00
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Subtotal (Total Children Is Unduplicated) 1234 5108 67952.32 $2558750.03 $37.66
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Total 7904 71888.03 $2815563.11 $39.17
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Number of Children (Unduplicated) With at Least One Authorization 1546