Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.62 $59.81 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 1.62 $59.81 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 8 32.20 $1932.24 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 7 8.07 $377.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 5.18 $619.92 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 25 49.45 $3203.18 $64.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 11.38 $569.17 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 13 16.00 $800.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 20 45.90 $2295.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 2.70 $67.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 53 90.41 $4520.49 $50.00
CONOP -CONOP CONSULT, OT, PHONE 11 14 16.85 $421.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 28 55.45 $2772.27 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 13 12.27 $306.87 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 44 50 90.74 $4536.92 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 20 20.68 $517.08 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 63 1108.29 $27707.16 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 198 257 1840.10 $92004.75 $50.00
INTR -INTR INTERPRETER 13 14 71.57 $3578.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 107 138 740.64 $50274.87 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 55.86 $3034.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 175 231 1424.42 $96689.83 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 3.87 $210.10 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 11 11.00 $11.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 5 4.50 $2250.00 $500.00
SENS -V5264 EARMOLD 4 5 3.38 $63.23 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 309 403 2434.39 $165246.40 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 50.00 $660.00 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 3 2.53 $253.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 9 107.93 $5396.43 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 544 1377 8224.86 $468711.39 $56.99
-----------------------------------------------------------------------------------------------------------------------------
Total 1404 8275.93 $471974.39 $57.03
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 546