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: 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 1 1 0.10 $3.70 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.10 $3.70 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 8 6.07 $364.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.02 $122.26 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 4 14.14 $707.14 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 15.00 $1125.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 16 30.00 $2250.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.00 $242.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.00 $582.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 31 33 141.14 $6845.44 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 69 108 253.37 $14309.83 $56.48
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 5 30.98 $1549.06 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 114 131 231.54 $11576.87 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 86 147.12 $7355.76 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.27 $56.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 89 151.58 $7579.21 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.62 $115.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 103 160.68 $8034.15 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 4 16.14 $1185.21 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 110.00 $2750.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 26.29 $1314.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 149 170 1772.85 $88642.47 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 3 8.37 $418.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 113 142 1339.59 $90931.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 27.57 $1497.68 $54.32
PHY -97110 PT SESSION BY LICENSED PT 120 144 1511.37 $102591.51 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 73.70 $4003.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -V5264 EARMOLD 1 1 1.02 $19.14 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 9.64 $481.91 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 159 194 1822.00 $123677.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 61.00 $805.20 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6 7 1392.86 $696.43 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 51.43 $2571.44 $50.00
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Subtotal (Total Children Is Unduplicated) 310 1115 8956.61 $457906.45 $51.12
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Total 1224 9210.09 $472219.98 $51.27
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Number of Children (Unduplicated) With at Least One Authorization 329