Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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 185 187 168.38 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 6 18.57 $687.15 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 8.20 $303.28 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 194 203 198.15 $990.42 $5.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 51 56.86 $2757.57 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 18 18 30.49 $1099.68 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 59 59 59.00 $626.58 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 59 59 59.00 $520.97 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 57 57 57.00 $615.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 53 53 53.00 $1154.87 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 52.00 $1470.56 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 201 222 239.05 $14343.23 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 24 29 30.07 $1407.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 143 149 160.12 $19149.95 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 8 11.70 $1462.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 38 39 92.76 $11594.86 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 194 219 319.43 $15971.47 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 62 70 112.04 $5601.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 3.00 $225.00 $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 15 15 19.57 $1467.86 $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 26 26 37.00 $2053.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 20.00 $1110.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 262 262 403.00 $30225.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 51 51 74.50 $5587.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 106 107 179.64 $13473.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 287 287 435.89 $24191.92 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 229 250 371.86 $27889.29 $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 94 111 135.49 $6571.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 552 621 712.52 $34557.37 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 98 114 120.43 $5840.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 480 522 569.77 $27633.96 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 9 9 9.00 $450.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1144 1268 1466.65 $71132.34 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 8.00 $800.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 7 7 13.57 $678.57 $50.00
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Subtotal (Total Children Is Unduplicated) 2798 4775 5949.26 $334821.92 $56.28
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 77 93 106.00 $159000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.02 $70.40 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 97 110 250.54 $12527.17 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 415 817 1504.75 $75237.51 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 19 21 20.75 $518.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1375 1658 3284.04 $164202.03 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 75 83 150.56 $3764.11 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 655 781 1372.79 $68639.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 32 36 48.70 $1217.51 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 515 611 1169.71 $58485.58 $50.00
CONPP -CONPP CONSULT, PT, PHONE 40 44 62.85 $1571.28 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1350 1620 2818.60 $140930.15 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 92 106 160.40 $4010.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 25 27 95.39 $7003.53 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 10 10 1511.29 $18891.07 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 5 5 9.90 $247.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 324 389 3007.40 $75184.97 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 7 73.57 $3678.58 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 0.80 $40.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 27 29 285.29 $14264.31 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 3 3 32.71 $1635.72 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 7 38.14 $953.58 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3895 4914 37060.72 $1853035.91 $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 48 58 306.51 $15325.59 $50.00
INTR -INTR INTERPRETER 99 116 738.82 $36940.75 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1807 2317 14904.71 $1011732.00 $67.88
OCCT -97530HM OT SESSION BY OT ASST 145 163 997.72 $54196.01 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2192 2796 18235.98 $1237858.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 176 185 1088.80 $59143.41 $54.32
RSPT -RSPT RESPITE 1 1 49.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 329 344 576.30 $576.30 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 14 18.50 $9250.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 17 19 12.71 $826.31 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 11 13 24.00 $5690.88 $237.12
SENS -V5264 EARMOLD 49 58 93.42 $1748.76 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 66 77 314.81 $15740.37 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3531 4496 29717.96 $2017255.17 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 9 9 78.73 $4276.80 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 268 283 2252.03 $29726.85 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 9 11 46.53 $4653.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2724 4401 414038.14 $207019.03 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 31.57 $1578.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 70 89 557.12 $27855.84 $50.00
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Subtotal (Total Children Is Unduplicated) 7834 26831 537153.50 $7408502.65 $13.79
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Total 31809 543300.91 $7744314.99 $14.25
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Number of Children (Unduplicated) With at Least One Authorization 8109