Summary Report for FSPSAs Initiated During the Report Period Center: 57
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: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 25 30 17.73 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 9 11 8.50 $314.50 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
TCON -TCON TRANSITION CONFERENCE 4 4 4.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 28 46 31.23 $351.50 $11.26
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 29.86 $1076.95 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 21 21 21.02 $1261.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 6.00 $717.60 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 7 7 10.70 $1337.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 17 17 17.02 $2127.78 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 4 4 4.00 $120.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.06 $4.58 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.27 $20.42 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 5.00 $375.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 42 137.57 $6672.21 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 70 78 77.25 $3746.73 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 192 225 258.85 $12554.08 $48.50
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Subtotal (Total Children Is Unduplicated) 291 425 584.89 $31841.38 $54.44
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.00 $550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 359 460 1688.29 $84414.54 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 74 83 361.01 $9025.24 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 67.94 $3396.98 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 69.73 $3486.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 7.97 $199.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 379 488 1844.98 $92249.22 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 60 67 246.33 $6158.33 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 15 192.59 $14139.91 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 741.00 $9262.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 60.00 $1500.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 11.14 $278.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 504 698 11151.07 $557553.61 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 45 494.14 $33542.43 $67.88
OCCT -97530HM OT SESSION BY OT ASST 27 31 348.31 $18920.17 $54.32
PHY -97110 PT SESSION BY LICENSED PT 95 100 1135.32 $77065.50 $67.88
PHY -97110HM PT SESSION BY PT ASST 42 43 507.21 $27551.89 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 16 257.35 $12867.63 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 145 162 1228.09 $83362.56 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 27.29 $1482.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 43 46 429.93 $5675.05 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 16.00 $1600.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 526 917 16755.59 $8377.79 $0.50
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Subtotal (Total Children Is Unduplicated) 643 3223 37652.29 $1052659.90 $27.96
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Total 3694 38268.41 $1084852.78 $28.35
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Number of Children (Unduplicated) With at Least One Authorization 650