Summary Report for FSPSAs Initiated During the Report Period Center: 02
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 2 2 2.00 $120.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 23 23 44.00 $2200.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 3 4.00 $222.00 $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 97 97 168.00 $12600.00 $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 16 16 23.50 $1762.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 83 83 147.57 $8190.21 $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 3 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 13.00 $630.50 $48.50
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Subtotal (Total Children Is Unduplicated) 166 337 558.64 $37143.22 $66.49
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.03 $101.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 7 7.53 $376.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.10 $77.47 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.53 $126.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.63 $40.83 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 15 18.06 $903.10 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.95 $173.81 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 637.86 $7973.22 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 68 389.14 $19457.12 $50.00
INTR -INTR INTERPRETER 2 2 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 38 38 297.69 $20206.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 55.86 $3034.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 24 24 133.30 $9048.63 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 28.57 $1552.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 17.00 $17.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 6.86 $342.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 57 372.10 $25258.44 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 188.80 $2492.22 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 9.41 $470.48 $50.00
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Subtotal (Total Children Is Unduplicated) 181 266 2192.44 $103928.21 $47.40
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Total 614 2764.33 $141228.68 $51.09
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Number of Children (Unduplicated) With at Least One Authorization 242