Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 4.07 $150.47 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.02 $74.82 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 6.09 $225.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 6.00 $360.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 8 126.86 $15857.16 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 13 16.01 $800.56 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.50 $262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 15.00 $832.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 122 177 286.63 $21497.51 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 6.23 $302.32 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 86 92 85.04 $4124.65 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 13 18.93 $918.23 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 98 111 143.55 $6962.13 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 219 242 232.35 $11268.92 $48.50
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Subtotal (Total Children Is Unduplicated) 407 692 954.11 $63816.73 $66.89
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 22 42.15 $2107.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.90 $122.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 22 43.34 $2166.85 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 6.20 $155.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 23 52.35 $2617.26 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 12.55 $313.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 26 72.76 $3638.10 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 12.46 $311.46 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 25 64.12 $3206.24 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 9 21.81 $545.33 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 9 10 912.86 $11410.71 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 57.14 $1428.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 486 687 9986.06 $499302.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 15 241.91 $12095.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 89 107 1582.14 $107395.88 $67.88
OCCT -97530HM OT SESSION BY OT ASST 50 61 854.76 $46430.55 $54.32
PHY -97110 PT SESSION BY LICENSED PT 126 172 2838.80 $192697.46 $67.88
PHY -97110HM PT SESSION BY PT ASST 59 72 1184.14 $64322.50 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 21 26.86 $26.86 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 2 2 4.78 $89.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 260 341 5220.51 $354368.25 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 45.43 $2467.68 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 120 133 2150.59 $28387.76 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2 2 39.00 $19.50 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 28.68 $1434.17 $50.00
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Subtotal (Total Children Is Unduplicated) 837 1787 25519.30 $1348461.70 $52.84
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Total 2482 26479.50 $1412503.72 $53.34
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Number of Children (Unduplicated) With at Least One Authorization 893