Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 3 3 3.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 58.00 $2146.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 7.43 $274.86 $37.00
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Subtotal (Total Children Is Unduplicated) 6 7 68.43 $2420.86 $35.38
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 3 3.00 $163.14 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 148 168 182.12 $10927.15 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.73 $127.92 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 53 57 56.73 $6785.30 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 14 29.43 $3678.58 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 26 29 45.08 $2186.20 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 135 151 169.43 $8217.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 27 28 41.29 $2002.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 84 86 118.86 $5764.57 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 263 304 325.29 $15776.36 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 458 855 985.95 $56664.66 $57.47
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 15 17 95.63 $4781.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 13 72.61 $3630.48 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 8 18.77 $469.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 192 256 963.81 $48190.72 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 30 33 99.78 $2494.44 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 148 404.99 $20249.53 $50.00
CONOP -CONOP CONSULT, OT, PHONE 20 24 69.05 $1726.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 57 203.38 $10169.11 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 13 42.17 $1054.16 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 167 218 658.96 $32948.16 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 29 30 84.15 $2103.81 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.36 $687.00 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 13.00 $325.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 18.86 $942.86 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.00 $50.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 51 55 535.44 $26772.13 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 5.71 $142.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 406 597 9339.62 $466981.24 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.33 $116.67 $50.00
INTR -INTR INTERPRETER 31 53 540.47 $27023.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 243 363 5918.73 $401763.30 $67.88
OCCT -97530HM OT SESSION BY OT ASST 43 53 815.40 $44292.65 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 263 3672.35 $249279.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 29 33 458.24 $24891.35 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 16.00 $16.00 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 1.03 $245.02 $237.12
SENS -V5264 EARMOLD 8 10 45.74 $856.34 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 81.87 $4093.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 297 456 6046.13 $410411.27 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 31.14 $1691.68 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 44 49 699.11 $9228.22 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 594 1277 279537.27 $139768.63 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.29 $114.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 172.00 $8600.00 $50.00
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Subtotal (Total Children Is Unduplicated) 790 4083 310687.41 $1953244.07 $6.29
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Total 4945 311741.78 $2012329.59 $6.46
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Number of Children (Unduplicated) With at Least One Authorization 807