Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 09
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 556 576 829.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 556 576 829.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.00 $194.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 3.39 $122.24 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 4.12 $247.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 5.00 $277.50 $55.50
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 37 39 40.00 $1940.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 23 23.00 $1115.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 16 16.00 $776.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 90 117 120.51 $6246.53 $51.83
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 8.00 $12000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 3 4.07 $280.03 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.93 $64.27 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 17 19 158.53 $7926.43 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 29 36.37 $1818.33 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 60 96.27 $4813.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 26 26.00 $1300.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 85 119.92 $5996.19 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 17 19 136.21 $10000.85 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.00 $25.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 13.00 $650.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 21.00 $1050.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 49 50 774.25 $38712.62 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 374 610 7530.46 $376523.19 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 2.93 $146.43 $50.00
INTR -INTR INTERPRETER 4 6 35.71 $1785.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 458 898 10064.65 $683188.27 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 12 131.46 $7140.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 475 940 12295.05 $834587.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 28.43 $1544.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.00 $8.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 4 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 12 12 7.29 $474.05 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 6.13 $1454.33 $237.12
SENS -V5264 EARMOLD 18 20 62.44 $1168.93 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 6.68 $333.81 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 816 1577 18674.00 $1267591.35 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 41.14 $2234.88 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 19.29 $254.57 $13.20
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Subtotal (Total Children Is Unduplicated) 1186 4419 50317.22 $3265673.42 $64.90
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Total 5112 51267.16 $3271919.96 $63.82
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Number of Children (Unduplicated) With at Least One Authorization 1201