Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 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
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
EXIT -EXIT TRANSITION ASSESSMENT 7 7 13.00 $650.00 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.00 $242.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 76 147 219.53 $14229.73 $64.82
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
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
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 6.00 $300.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.87 $171.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 2 0.75 $37.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.33 $33.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 8.22 $411.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.33 $33.33 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 385.71 $4821.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 133.57 $3339.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 40 40 285.53 $14276.68 $50.00
INTR -INTR INTERPRETER 2 2 8.43 $421.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 13 14 88.65 $6017.40 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 18.14 $985.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 14 14 105.44 $7157.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 11.00 $597.52 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.00 $8.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 23 174.86 $11869.32 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 84.29 $1112.57 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.14 $607.15 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 92 140 1343.77 $53825.76 $40.06
-----------------------------------------------------------------------------------------------------------------------------
Total 288 1564.31 $68055.48 $43.51
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 119