Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01/01/09 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 7 7 9.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 2.00 $74.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 8 11 13.25 $157.25 $11.87
Screening, Eval, and Assessment, Class # 02
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.00 $100.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 12 12 23.00 $1150.00 $50.00
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 65 65 115.50 $8662.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 19 19 26.00 $1950.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 18.50 $1387.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 51 51 82.00 $4551.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 34 60.07 $4505.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.00 $242.50 $48.50
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Subtotal (Total Children Is Unduplicated) 105 204 338.07 $22853.50 $67.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 14.03 $701.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 3 4.25 $212.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 6.50 $162.50 $25.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.60 $65.00 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 10.55 $527.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 5.50 $137.50 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 72.86 $910.71 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 41 41 292.43 $14621.43 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 22 24 135.95 $9228.46 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 28.00 $1520.97 $54.32
PHY -97110 PT SESSION BY LICENSED PT 9 9 69.90 $4744.49 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 4 27.18 $1476.34 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 25 191.07 $12969.92 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 62.71 $827.83 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.39 $169.29 $50.00
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Subtotal (Total Children Is Unduplicated) 100 152 936.92 $51607.42 $55.08
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Total 367 1288.23 $74618.17 $57.92
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Number of Children (Unduplicated) With at Least One Authorization 192