Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10/01/08 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 6 7 10.00 $500.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 32 32 53.00 $3975.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 20 29.00 $2175.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 18 18 25.50 $1912.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 51 51 78.03 $4330.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 6.00 $450.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 83 149 218.53 $14233.85 $65.13
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.50 $25.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.47 $11.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 16.32 $816.19 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 13.10 $655.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.10 $52.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 2 0.75 $37.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.18 $54.58 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 17.85 $892.74 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.10 $52.50 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 234.00 $2925.00 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 44 281.52 $14076.19 $50.00
INTR -INTR INTERPRETER 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 19 19 96.89 $6576.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 21.93 $1191.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 16 17 100.35 $6811.51 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 6.54 $355.02 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 26 190.43 $12926.29 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 86.43 $1140.86 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.43 $321.43 $50.00
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Subtotal (Total Children Is Unduplicated) 97 165 1086.89 $49050.97 $45.13
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Total 315 1306.42 $63284.82 $48.44
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Number of Children (Unduplicated) With at Least One Authorization 166