Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 35.87 $1327.06 $37.00
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Subtotal (Total Children Is Unduplicated) 7 7 35.87 $1327.06 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 17 19 23.20 $1391.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.98 $595.34 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 14 15 40.77 $2038.58 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 31.14 $2335.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 14.00 $1050.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 21.00 $1575.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 12.00 $666.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 47 49 66.14 $4960.72 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 29 123.57 $5993.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 12 11.52 $558.83 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 26 26.00 $1261.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 61 68 246.71 $11965.64 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 9 12 15.57 $778.57 $50.00
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Subtotal (Total Children Is Unduplicated) 177 306 653.61 $36470.97 $55.80
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 12 92.02 $4600.95 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 195 299 699.78 $34989.18 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 111 164 300.10 $15005.18 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.91 $122.77 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 117 167 347.18 $17359.09 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 17.33 $433.13 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 164 269.56 $13477.83 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 8 51.86 $3807.36 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 3 3 138.00 $3450.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 14 1191.86 $29796.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 208.29 $10414.29 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 51 51 274.85 $13742.39 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 44.71 $1117.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 273 391 7653.51 $382675.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 6 64.84 $3241.91 $50.00
INTR -INTR INTERPRETER 1 1 26.14 $1307.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 195 317 5943.34 $403433.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 15 354.39 $19250.50 $54.32
PHY -97110 PT SESSION BY LICENSED PT 192 324 6511.38 $441992.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 17 353.73 $19214.79 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -V5264 EARMOLD 3 3 5.02 $94.02 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 11 114.03 $5701.68 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 297 446 7530.74 $511186.84 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 275.00 $3630.00 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 57 88 116563.64 $58281.82 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 9.57 $478.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 10 84.40 $4219.77 $50.00
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Subtotal (Total Children Is Unduplicated) 550 2553 149139.18 $2006228.02 $13.45
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Total 2866 149828.66 $2044026.05 $13.64
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Number of Children (Unduplicated) With at Least One Authorization 582