Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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
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 1.00 $37.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 12.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 13.00 $37.00 $2.85
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 32 38 45.71 $2217.14 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.64 $38.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 152 165 240.14 $12007.14 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.00 $200.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 383 484 494.52 $23984.40 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 263 329 372.08 $18045.70 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 440 558 586.22 $28431.85 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.50 $125.00 $50.00
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Subtotal (Total Children Is Unduplicated) 850 1588 1756.83 $86157.90 $49.04
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 29 31 63.60 $3180.24 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 261 371 733.03 $36651.43 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 111 157 263.85 $13192.39 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 116 190.89 $9544.30 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 236 419.51 $20975.48 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.50 $12.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 9 10.36 $760.30 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 102 144 964.32 $24108.10 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 901 1259 9182.66 $459133.03 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 485 667 3605.49 $244740.66 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.21 $337.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 394 553 3054.18 $207317.87 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 48 56 45.79 $45.79 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 5 5 13.53 $253.34 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 23 26 89.28 $4464.05 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 12.86 $642.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 559 749 3837.04 $260458.21 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 3 9.93 $131.06 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 7 7 36.64 $3664.28 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 811 1227 6282.49 $3141.25 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 13 66.94 $3347.02 $50.00
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Subtotal (Total Children Is Unduplicated) 1287 5637 28896.11 $1299166.71 $44.96
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Total 7227 30665.93 $1385361.60 $45.18
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Number of Children (Unduplicated) With at Least One Authorization 1327