Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 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 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 0.29 $10.57 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 14.57 $539.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 1.96 $72.68 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5 7 16.82 $622.39 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 37 38.00 $1843.00 $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 51 54 60.08 $3604.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 5.29 $247.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 22 23 31.00 $3707.60 $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 655 705 964.00 $72300.01 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 30 32 138.57 $6720.71 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 63 66 99.71 $4836.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 50 53 94.71 $4593.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 74 77 132.00 $6402.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 203 217 336.22 $16306.44 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1401 2922 4180.37 $269287.19 $64.42
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 55 86 95.00 $142500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 18 19 25.97 $1298.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 121 129 177.89 $8894.41 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 22 27 60.97 $1524.28 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 35 67.07 $3353.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 20 23 110.23 $2755.71 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 9.70 $485.00 $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 39 42 120.73 $6036.38 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 41 44 127.99 $3199.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 105.71 $1321.43 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 8 9 186.14 $4653.57 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 73 1369.86 $34246.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 62.00 $3100.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 121 123 1066.48 $53324.03 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 608 824 12179.77 $608988.69 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 39.29 $1964.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 21.86 $1092.86 $50.00
INTR -INTR INTERPRETER 44 59 1262.11 $63105.61 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 180 267 4083.12 $277162.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 40 43 654.78 $35567.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 314 496 8529.11 $578955.73 $67.88
PHY -97110HM PT SESSION BY PT ASST 54 56 921.95 $50080.47 $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 2 2 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 7 11 18.28 $342.24 $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 794 1202 18968.32 $1287569.65 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 20 20 217.86 $11833.99 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 74 79 1206.29 $15922.97 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 30.14 $3014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1186 2576 33935.49 $16967.74 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 100.86 $5042.86 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 9 162.00 $8100.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1402 6369 87270.34 $3250257.18 $37.24
-----------------------------------------------------------------------------------------------------------------------------
Total 9298 91467.53 $3520166.76 $38.49
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1700