Summary Report for FSPSAs Ending During the Report Period Statewide
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 Page: 1
Payor Filter: PARH PAHM DEI DEIM
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 123 123 123.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 124 124 124.00 $37.00 $0.30
Screening, Eval, and Assessment, Class # 02
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.00 $450.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 1 1 4.00 $120.00 $30.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 3.00 $450.00 $150.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 4.00 $200.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 16 16 24.00 $1515.50 $63.15
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.68 $34.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.93 $46.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.00 $100.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 10.00 $500.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 9 9 57.43 $2871.43 $50.00
INTR -INTR INTERPRETER 1 1 4.86 $242.86 $50.00
PHY -97110 PT SESSION BY LICENSED PT 1 1 11.57 $785.47 $67.88
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 20.43 $1386.69 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6 6 83.36 $41.68 $0.50
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Subtotal (Total Children Is Unduplicated) 18 22 191.26 $6008.95 $31.42
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Total 162 339.26 $7561.45 $22.29
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Number of Children (Unduplicated) With at Least One Authorization 148