Summary Report for FSPSAs Initiated During the Report Period Center: 54
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 42 48 48.00 $2880.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 16 16.00 $1913.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $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 30 31 32.29 $1565.86 $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 17 17 17.00 $824.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 61 63 67.00 $3249.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 137 191 196.29 $11619.96 $59.20
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.10 $155.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.57 $14.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 73 75 122.21 $6110.71 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 2.13 $53.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 38 65.40 $3269.90 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.47 $111.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 25.13 $1256.66 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 66 90.56 $4527.96 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.83 $20.83 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.86 $292.86 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 132 147 994.23 $49711.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.33 $116.67 $50.00
INTR -INTR INTERPRETER 13 14 96.11 $4805.37 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 68 70 469.99 $31902.62 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 9 35.50 $1928.35 $54.32
PHY -97110 PT SESSION BY LICENSED PT 44 44 223.81 $15192.35 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 27.54 $1495.74 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 12.00 $12.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.33 $116.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 92 98 657.00 $44597.39 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.57 $465.60 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 59.11 $780.22 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 210 308 37709.61 $18854.80 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.71 $185.72 $50.00
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Subtotal (Total Children Is Unduplicated) 278 929 40625.11 $186128.23 $4.58
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Total 1122 40823.39 $197748.19 $4.84
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Number of Children (Unduplicated) With at Least One Authorization 292