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
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 20 20 38.00 $1900.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 2 3.00 $166.50 $55.50
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 96 96 166.00 $12450.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 44 44 63.00 $4725.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 15 22.50 $1687.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 82 82 131.00 $7270.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 45 45 78.57 $5892.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 8.00 $388.00 $48.50
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Subtotal (Total Children Is Unduplicated) 164 325 527.07 $35339.00 $67.05
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $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 9 11 28.51 $1425.48 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 7.50 $187.50 $25.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 13.46 $336.43 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 22.80 $1140.24 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 9.07 $226.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 774.00 $9675.00 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 64 65 511.07 $25553.57 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 38 214.02 $14527.96 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 54.20 $2943.89 $54.32
PHY -97110 PT SESSION BY LICENSED PT 14 14 84.40 $5729.23 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 40.18 $2182.50 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 58 424.93 $28844.15 $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 14 14 113.40 $1496.82 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 6.52 $325.95 $50.00
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Subtotal (Total Children Is Unduplicated) 170 273 2335.09 $104778.36 $44.87
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Total 609 2875.40 $140274.61 $48.78
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Number of Children (Unduplicated) With at Least One Authorization 303