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: 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
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 85 92 89.13 $5348.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 29 29 29.00 $3468.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 15 16.14 $782.70 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 58 59.29 $2875.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 13 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 40 52.14 $2528.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 142 148 153.00 $7420.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 260 409 425.70 $24332.86 $57.16
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 22.86 $1143.02 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 16.43 $821.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 2.33 $58.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 141 157 342.65 $17132.43 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 10 10 9.17 $229.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 80 141.13 $7056.70 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 7 8.87 $221.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 32 62.10 $3104.95 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.22 $130.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 141 246.64 $12331.76 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 11 16.00 $400.06 $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 -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 26.29 $1314.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 281 349 2854.35 $142717.31 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.33 $116.67 $50.00
INTR -INTR INTERPRETER 26 33 210.64 $10532.16 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 141 178 1407.80 $95561.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 17 19 128.79 $6995.64 $54.32
PHY -97110 PT SESSION BY LICENSED PT 99 118 794.94 $53960.39 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 10 57.34 $3114.87 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 16.00 $16.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 5 5 9.20 $172.22 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 7.60 $380.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 228 1778.83 $120746.66 $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 23 23 147.79 $1950.77 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 403 697 111976.84 $55988.41 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 64.00 $3200.01 $50.00
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Subtotal (Total Children Is Unduplicated) 515 2157 120374.55 $541270.66 $4.50
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Total 2570 120807.96 $565814.95 $4.68
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Number of Children (Unduplicated) With at Least One Authorization 525