Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 26.93 $996.36 $37.00
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Subtotal (Total Children Is Unduplicated) 5 5 26.93 $996.36 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 8 9.00 $436.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.00 $43.58 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 34 34 33.82 $2029.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 12.00 $1435.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 5.50 $275.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 38 40 57.96 $2898.22 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 18 23.50 $1762.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $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 6 7 10.50 $787.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 25.50 $1415.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 196 196 276.00 $20700.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 11.00 $825.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 67 67 105.50 $7912.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 194 195 268.00 $14874.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 196 200 268.00 $20100.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 12.86 $623.57 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 19.86 $963.07 $48.50
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Subtotal (Total Children Is Unduplicated) 428 845 1176.00 $78844.95 $67.04
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 12 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 7 8.23 $411.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 45 49 62.83 $3141.31 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 12 12 5.25 $131.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 15 21.78 $1089.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 16 24.81 $620.36 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.80 $140.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.20 $5.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 18.48 $924.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 11 21.93 $548.22 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 34.78 $1739.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 29 31 30.72 $767.98 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 41 1380.39 $34509.64 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 22.93 $1146.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 469 574 3825.60 $191280.09 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 16.06 $802.86 $50.00
INTR -INTR INTERPRETER 55 69 441.46 $22073.07 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 87 102 937.21 $63618.02 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 62.57 $3398.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 190 229 1897.81 $128823.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 9 80.57 $4376.64 $54.32
RSPT -RSPT RESPITE 2 2 70.93 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 66 70 249.29 $249.29 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 4 5 5.82 $108.99 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 8 31.43 $1571.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 509 652 5158.74 $350174.98 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.43 $512.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 42 50 385.97 $5094.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.71 $971.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 813 1450 9584.24 $4792.13 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 57.86 $2892.86 $50.00
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Subtotal (Total Children Is Unduplicated) 986 3475 24475.85 $844691.71 $34.51
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Total 4325 25678.78 $924533.01 $36.00
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Number of Children (Unduplicated) With at Least One Authorization 1074