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: 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 21 23 9.76 $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
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Subtotal (Total Children Is Unduplicated) 22 31 17.76 $185.00 $10.42
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 24.14 $870.83 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 9.04 $542.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $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 10 10 9.04 $1130.55 $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 27 31 93.71 $4545.15 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 58 64 64.00 $3104.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 153 176 177.72 $8619.45 $48.50
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Subtotal (Total Children Is Unduplicated) 222 318 407.15 $22223.23 $54.58
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.00 $550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 297 359 723.39 $36169.69 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 37 43 72.63 $1815.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 20.03 $1001.51 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 9.70 $485.01 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.73 $43.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 299 364 697.66 $34882.81 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 29 32 59.10 $1477.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 45.86 $3366.78 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 1.00 $12.50 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 11.14 $278.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 355 452 3721.86 $186092.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 30 32 233.14 $15825.75 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 9 37.11 $2015.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 67 70 391.90 $26601.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 25 25 132.07 $7174.12 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 11 113.40 $5670.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 109 121 543.66 $36903.80 $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 22 22 117.29 $1548.17 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 383 604 7427.43 $3713.70 $0.50
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Subtotal (Total Children Is Unduplicated) 457 2179 14384.38 $366351.36 $25.47
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Total 2528 14809.29 $388759.59 $26.25
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Number of Children (Unduplicated) With at Least One Authorization 465