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: 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 7 7 2.40 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 4.00 $148.00 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 9 14 9.40 $148.00 $15.74
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 8 8 8.00 $288.56 $36.07
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 8.70 $1087.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 7.00 $875.00 $125.00
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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 23 23.00 $1115.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 64 66 70.14 $3401.93 $48.50
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Subtotal (Total Children Is Unduplicated) 87 122 140.63 $8839.20 $62.85
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 143 151 231.41 $11570.70 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 19 29.23 $730.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.58 $178.89 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.50 $25.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 145 225.85 $11292.37 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 15 15 20.23 $505.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 23.71 $1741.11 $73.42
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 11.14 $278.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 169 178 1191.14 $59556.97 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 16 17 109.71 $7447.41 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.43 $186.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 26 26 97.21 $6598.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 5.43 $294.88 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 16.71 $835.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 77 275.42 $18695.50 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 19.50 $257.40 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 179 220 2878.73 $1439.37 $0.50
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Subtotal (Total Children Is Unduplicated) 206 871 5147.96 $121885.68 $23.68
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Total 1007 5297.98 $130872.88 $24.70
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Number of Children (Unduplicated) With at Least One Authorization 209