Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 1.19 $44.19 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 1.19 $44.19 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 27.29 $3410.73 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 33 49 83.00 $6225.00 $75.00
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 46 50 41.53 $2014.09 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 56 59 43.51 $2110.41 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 127 129 121.25 $5880.58 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 202 302 329.58 $20233.78 $61.39
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 5 11.05 $552.38 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 9 16.40 $819.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.60 $115.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 19 29.80 $1489.77 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.58 $164.59 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 20 36.31 $1815.60 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.45 $111.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 17 31.28 $1564.15 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 9.97 $249.17 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 102.00 $1275.00 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 13.57 $339.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 351 426 3110.42 $155521.19 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 74.53 $3726.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 67 75 630.36 $42788.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 35 43 253.77 $13785.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 102 124 1114.23 $75633.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 40 44 325.21 $17665.37 $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 206 240 2015.16 $136789.17 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 26.86 $1458.88 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 68 71 575.70 $7599.19 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 15.47 $773.45 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 637 1158 8446.35 $471103.53 $55.78
-----------------------------------------------------------------------------------------------------------------------------
Total 1462 8777.12 $491381.50 $55.98
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 656