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
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 2 2 2.43 $89.86 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 4.29 $158.57 $37.00
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Subtotal (Total Children Is Unduplicated) 5 6 9.71 $248.43 $25.57
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 148 160 154.00 $9239.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 54 56 74.00 $8850.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 11 11.00 $1375.00 $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
NURS -NURS NURSING ASSESSMENT 4 4 2.80 $140.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 24 25 26.14 $1267.70 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 105 112 113.29 $5494.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 15 15 16.33 $792.17 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 63 64 83.71 $4060.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 227 240 255.43 $12388.29 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 446 703 752.70 $44684.50 $59.37
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 21 21 37.43 $1871.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 17 31.53 $1576.68 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 5.47 $136.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 213 241 501.26 $25063.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 15 15 16.97 $424.35 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 126 156 266.07 $13303.26 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 10.07 $251.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 46 81.35 $4067.44 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 9 16.71 $417.68 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 204 241 411.34 $20566.89 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 17 19 31.61 $790.25 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 19.00 $950.00 $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 456 573 5007.13 $250356.45 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 18.01 $900.48 $50.00
INTR -INTR INTERPRETER 29 37 242.51 $12125.73 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 289 385 3223.55 $218814.87 $67.88
OCCT -97530HM OT SESSION BY OT ASST 33 37 231.36 $12567.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 165 210 1538.58 $104438.72 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 16 107.20 $5823.11 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 23.00 $23.00 $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 3 3 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5264 EARMOLD 11 11 14.98 $280.38 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 15.10 $755.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 382 481 4005.02 $271860.79 $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 45 47 330.55 $4363.29 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 676 1162 209316.93 $104658.46 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 7 77.14 $3857.15 $50.00
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Subtotal (Total Children Is Unduplicated) 906 3792 225626.73 $1068667.16 $4.74
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Total 4501 226389.14 $1113600.10 $4.92
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Number of Children (Unduplicated) With at Least One Authorization 919