Summary Report for FSPSAs Ending During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 11 11 4.32 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 4.00 $148.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 19 12.32 $185.00 $15.02
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 9.04 $542.33 $60.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 0.04 $5.55 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.50 $112.50 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 18.00 $873.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 55 55 52.58 $2550.02 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 86 102 98.16 $5165.48 $52.62
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 112 118 189.98 $9498.82 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 22 26.53 $663.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 10.32 $515.96 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.73 $43.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 131 182.85 $9142.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 14 19.80 $495.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 9.00 $660.72 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 1.00 $12.50 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 161 173 1020.71 $51035.74 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 11 12 71.57 $4858.27 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 7 17.40 $944.92 $54.32
PHY -97110 PT SESSION BY LICENSED PT 28 28 117.25 $7959.09 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 16 77.36 $4202.04 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 34.91 $1745.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 107.81 $7318.43 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 13.29 $721.68 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 45.21 $596.83 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 169 254 1227.13 $613.56 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 206 827 3176.86 $101178.43 $31.85
-----------------------------------------------------------------------------------------------------------------------------
Total 948 3287.34 $106528.91 $32.41
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 217