Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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
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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.00 $100.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 18 18 34.00 $1700.00 $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 13 13 19.50 $1462.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 52 52 98.57 $5470.71 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 34 60.07 $4505.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 12.00 $582.00 $48.50
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Subtotal (Total Children Is Unduplicated) 119 224 378.64 $24997.60 $66.02
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $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 3 5 5.28 $264.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 9 13.81 $345.33 $25.00
CONOP -CONOP CONSULT, OT, PHONE 6 6 6.23 $155.83 $25.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.50 $62.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 15 27.61 $1380.60 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 10 16.17 $404.17 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 5 1096.43 $13705.36 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 257.14 $6428.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 113 124 998.93 $49946.36 $50.00
INTR -INTR INTERPRETER 3 3 15.86 $792.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 56 452.07 $30686.26 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 11 84.07 $4566.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 41 43 394.66 $26789.70 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 7 70.75 $3843.14 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 18 27.00 $27.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 6.86 $342.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 61 72 610.64 $41450.38 $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 17 17 321.38 $4242.16 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 25.65 $1282.62 $50.00
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Subtotal (Total Children Is Unduplicated) 243 425 4455.08 $193672.60 $43.47
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Total 660 4846.96 $218827.44 $45.15
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Number of Children (Unduplicated) With at Least One Authorization 270