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: 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 144 144 131.94 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 5.43 $200.86 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 5.66 $209.55 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 155 157 146.03 $410.40 $2.81
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 28 31.86 $1545.07 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.34 $84.56 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 58 58 58.00 $615.96 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 56 56 56.00 $494.48 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 55 55 55.00 $594.00 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 52 52.00 $1133.08 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 51 51 51.00 $1442.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 126 132 136.57 $8194.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 15.03 $703.56 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 63 63 70.52 $8433.79 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 3.00 $375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 8.04 $1005.55 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 88 96 98.86 $4943.14 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 48 55 87.04 $4351.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.00 $150.00 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 18.57 $1392.86 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 6.00 $450.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 7.00 $525.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 4.57 $342.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 33.00 $1831.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 8.00 $444.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 244 244 368.00 $27600.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 46 46 64.50 $4837.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 95 96 157.64 $11823.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 269 269 400.89 $22249.42 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 224 245 364.36 $27326.79 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 54 56 55.07 $2670.96 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 279 301 307.59 $14918.26 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 51 54 54.00 $2619.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 221 226 260.01 $12610.51 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 7 7 7.00 $350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 530 553 586.55 $28447.79 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 12.57 $628.57 $50.00
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Subtotal (Total Children Is Unduplicated) 1720 2842 3447.60 $195544.69 $56.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 53 62 70.00 $105000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.47 $32.14 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 54 54 98.07 $4903.38 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 288 443 753.14 $37657.03 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 16 18 17.12 $427.92 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 618 647 1052.73 $52636.39 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 35 38 48.00 $1200.12 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 321 338 494.41 $24720.32 $50.00
CONOP -CONOP CONSULT, OT, PHONE 13 14 11.91 $297.71 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 219 226 354.38 $17718.93 $50.00
CONPP -CONPP CONSULT, PT, PHONE 22 23 22.58 $564.38 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 604 646 917.61 $45880.63 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 47 53 62.03 $1550.86 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 12 24.71 $1814.47 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 297.57 $3719.64 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 1.67 $41.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 174 186 1086.26 $27156.56 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 6.86 $342.86 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.57 $28.34 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 11 88.86 $4442.86 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 2 2 6.43 $321.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 20.14 $503.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1861 2036 11428.78 $571438.80 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 0.14 $7.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 20 23 101.93 $5096.53 $50.00
INTR -INTR INTERPRETER 50 53 253.68 $12683.93 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 971 1086 5286.65 $358857.57 $67.88
OCCT -97530HM OT SESSION BY OT ASST 61 64 305.68 $16604.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1097 1213 5525.15 $375047.34 $67.88
PHY -97110HM PT SESSION BY PT ASST 76 76 374.21 $20327.05 $54.32
RSPT -RSPT RESPITE 1 1 49.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 96 98 231.83 $231.83 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 7.50 $3750.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 5.66 $368.10 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 14.00 $3319.68 $237.12
SENS -V5264 EARMOLD 26 26 36.49 $683.07 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 30 31 104.50 $5225.12 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1775 2000 9802.33 $665381.99 $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 99 101 740.60 $9775.90 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 4 8.39 $838.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1343 1857 127077.29 $63538.64 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 31.57 $1578.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 37 40 220.86 $11043.09 $50.00
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Subtotal (Total Children Is Unduplicated) 4188 11526 167058.09 $2457822.34 $14.71
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Total 14525 170651.72 $2653777.43 $15.55
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Number of Children (Unduplicated) With at Least One Authorization 4808