Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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
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 30 31 31.02 $1861.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 8.00 $956.80 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 9 9 12.70 $1587.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 19 20 20.02 $2502.78 $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 42 48 149.00 $7226.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 81 93 92.25 $4474.23 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 205 244 279.13 $13537.94 $48.50
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Subtotal (Total Children Is Unduplicated) 325 482 648.61 $35571.23 $54.84
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 12.00 $600.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 25.89 $1294.29 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 11.67 $291.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 369 481 1813.15 $90657.65 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 84 98 416.64 $10416.07 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 71.61 $3580.32 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 14 74.60 $3730.01 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 7.97 $199.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 423 572 2308.75 $115437.35 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 92 111 428.52 $10713.10 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 22 24 257.94 $18938.06 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 746.71 $9333.93 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 60.00 $1500.00 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 66 67 485.43 $24271.41 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 11.14 $278.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 564 848 13496.93 $674846.48 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 64 72 697.07 $47317.23 $67.88
OCCT -97530HM OT SESSION BY OT ASST 30 35 363.88 $19766.02 $54.32
PHY -97110 PT SESSION BY LICENSED PT 140 159 1559.53 $105861.17 $67.88
PHY -97110HM PT SESSION BY PT ASST 44 45 519.29 $28207.61 $54.32
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 11.43 $571.43 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 20 311.60 $15580.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 221 256 1801.59 $122292.09 $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 48 52 465.79 $6148.37 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 16.00 $1600.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 614 1155 19864.22 $9932.10 $0.50
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Subtotal (Total Children Is Unduplicated) 764 4059 45866.64 $1324846.23 $28.88
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Total 4587 46546.47 $1360768.95 $29.23
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Number of Children (Unduplicated) With at Least One Authorization 771