Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 52 84 111.86 $5425.07 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 375 537 691.10 $34555.00 $50.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 325 451 526.21 $25521.16 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 287 415 491.83 $23853.69 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 416 556 656.08 $31819.92 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 4 5 40.86 $2042.86 $50.00
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Subtotal (Total Children Is Unduplicated) 976 2066 2536.93 $124727.84 $49.16
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 44 46 53.10 $2655.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 588 1100 4399.00 $219950.12 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 16 16 173.80 $4345.12 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 262 465 1834.03 $91701.50 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 27.29 $682.14 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 167 307 1232.21 $61610.44 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 20.57 $514.29 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 379 619 2245.94 $112297.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 14 148.30 $3707.62 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 32.25 $2367.50 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 15 15 132.84 $3320.99 $25.00
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 2 2 15.00 $187.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 259 466 3768.17 $94204.22 $25.00
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 7.71 $385.72 $50.00
EIIF -90847 FAMILY PSYCHOTHERAPY WITH PATIENT 1 1 8.29 $414.29 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 145 152 1354.71 $67735.27 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 63.29 $1582.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 990 1887 32408.29 $1620414.74 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 430 790 6060.22 $411367.78 $67.88
PHY -97110 PT SESSION BY LICENSED PT 444 879 7627.26 $517738.22 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 55 75.33 $75.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 3 3 3.36 $62.82 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 2 2 10.85 $542.38 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 29 52 246.27 $12313.35 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 557 911 6720.05 $456157.11 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 9 9 64.43 $6442.87 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 884 1742 10908.60 $5454.29 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 2.80 $139.77 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 34 269.67 $13483.34 $50.00
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Subtotal (Total Children Is Unduplicated) 1384 9590 79918.12 $3713877.89 $46.47
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Total 11658 82457.05 $3838605.73 $46.55
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Number of Children (Unduplicated) With at Least One Authorization 1464