Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 7 7.00 $420.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 13.00 $1554.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 7.14 $892.86 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 41 50 49.07 $2379.74 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 84 94 94.00 $4559.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 28 34 34.00 $1649.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 73 81 80.86 $3921.76 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 201 238 240.21 $11650.17 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 7.00 $700.00 $100.00
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Subtotal (Total Children Is Unduplicated) 269 521 532.28 $27727.33 $52.09
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 13.00 $19500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 12 34.86 $1742.86 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 12.82 $641.19 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 25.14 $1256.78 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 6 19.40 $970.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 9 33.36 $1667.97 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 4 14.95 $373.69 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 435.43 $10885.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 148.57 $3714.29 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 15.00 $750.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 156.43 $7821.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 9 10 79.86 $3992.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 76 113 1839.70 $91984.76 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 1 1 11.29 $564.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
INTR -INTR INTERPRETER 1 2 12.14 $607.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 232 367 5891.49 $399914.40 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 8 117.07 $6359.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 130 205 3124.16 $212068.10 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 12 80.58 $4377.33 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.17 $0.17 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 338 499 7435.10 $504694.48 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 26 26 251.00 $3313.20 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 136 217 13602.76 $6801.38 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 11.29 $564.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 28.43 $1421.43 $50.00
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Subtotal (Total Children Is Unduplicated) 452 1529 33395.98 $1286055.75 $38.51
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Total 2050 33928.26 $1313783.07 $38.72
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Number of Children (Unduplicated) With at Least One Authorization 467