Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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: 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 10 11 17.00 $850.00 $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 12 12 12.00 $582.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 7.00 $339.50 $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) 93 166 238.53 $15220.23 $63.81
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 13.64 $682.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.47 $11.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 9 9 17.32 $866.19 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 6.00 $150.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 13.10 $655.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 8 10.97 $274.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 2 0.75 $37.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 4.52 $112.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 35.03 $1751.31 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 5.43 $135.83 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 1408.29 $17603.57 $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 99 116 989.20 $49460.07 $50.00
INTR -INTR INTERPRETER 2 2 8.43 $421.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 46 320.31 $21742.30 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 125.50 $6817.17 $54.32
PHY -97110 PT SESSION BY LICENSED PT 32 38 327.36 $22221.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 10 79.96 $4343.67 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 14.00 $14.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 68 628.14 $42638.40 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 13.14 $713.92 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 19 21 236.43 $3120.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 34.78 $1739.06 $50.00
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Subtotal (Total Children Is Unduplicated) 218 400 4430.35 $180552.04 $40.75
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Total 567 4669.88 $195772.27 $41.92
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Number of Children (Unduplicated) With at Least One Authorization 239