Summary Report for FSPSAs Ending During the Report Period Center: 54
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 2.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.43 $52.86 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 4.29 $158.57 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 7.71 $211.43 $27.41
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 44 45 42.09 $2525.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 14.00 $1674.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 11.07 $536.96 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 36 36.00 $1746.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 21.00 $1018.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 76 79 80.00 $3880.00 $48.50
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Subtotal (Total Children Is Unduplicated) 147 221 218.16 $12353.88 $56.63
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 8.72 $435.88 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 10.27 $513.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.77 $44.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 48 50 97.10 $4854.89 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 7.03 $175.84 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 29 38.70 $1934.84 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.40 $110.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 13.03 $651.61 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.22 $130.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 52 76.83 $3841.74 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 8 12.10 $302.56 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.86 $292.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 121 134 807.33 $40366.45 $50.00
INTR -INTR INTERPRETER 15 17 67.64 $3382.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 84 88 628.96 $42694.11 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 59.64 $3239.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 45 48 263.79 $17906.07 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 16.66 $905.20 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5264 EARMOLD 3 3 6.13 $114.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 5.27 $263.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 103 662.64 $44980.17 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 49.25 $650.10 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 192 289 37452.19 $18726.09 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 34.00 $1700.00 $50.00
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Subtotal (Total Children Is Unduplicated) 265 892 40335.54 $188217.40 $4.67
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Total 1117 40561.41 $200782.71 $4.95
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Number of Children (Unduplicated) With at Least One Authorization 304