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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 151 151 151.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 151 151 151.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.34 $12.42 $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 3 3 3.06 $183.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.00 $717.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.00 $194.00 $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 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 21 28 28.40 $1714.02 $60.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.02 $70.40 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 14 15 53.51 $2675.40 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 21 23.00 $1150.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 39 46.80 $2340.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 21 21.00 $1050.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 65 68.67 $3433.33 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 7 19.14 $1405.47 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.00 $25.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 2.00 $100.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 274 361 2353.86 $117693.25 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.93 $96.43 $50.00
INTR -INTR INTERPRETER 3 3 28.29 $1414.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 317 440 2538.02 $172281.03 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 9 32.64 $1772.91 $54.32
PHY -97110 PT SESSION BY LICENSED PT 336 472 3084.89 $209402.19 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.00 $325.92 $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 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 9 3.46 $224.93 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 14 15 23.48 $439.59 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 5.68 $283.81 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 541 752 5020.76 $340809.03 $67.88
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Subtotal (Total Children Is Unduplicated) 822 2257 13355.15 $862498.68 $64.58
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Total 2436 13534.54 $864212.70 $63.85
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Number of Children (Unduplicated) With at Least One Authorization 838