Summary Report for FSPSAs Initiated During the Report Period Center: 05
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
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
Screening, Eval, and Assessment, Class # 02
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 14 15 27.00 $1350.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 14.00 $777.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 41 41 82.00 $6150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.00 $1800.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 25 25 50.00 $3750.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 50 50 100.00 $5550.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.00 $150.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 17 18.00 $873.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 20 21.00 $1018.50 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 103 200 358.00 $22772.00 $63.61
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 11 13.00 $19500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 128 260 520.00 $26000.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 132 136 272.00 $13600.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 57 114.00 $5700.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 82 86 174.60 $8730.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 105 111 222.00 $11100.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.60 $65.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 18 37.94 $948.40 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 18.00 $900.01 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 122 126 768.97 $38448.46 $50.00
INTR -INTR INTERPRETER 4 4 16.00 $800.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 30 33 138.57 $9405.91 $67.88
PHY -97110 PT SESSION BY LICENSED PT 59 63 267.13 $18132.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.64 $89.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 77 332.56 $22574.31 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 23.57 $311.14 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.29 $28.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 153 214 1103.01 $551.50 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 178 1209 4028.87 $176888.09 $43.91
-----------------------------------------------------------------------------------------------------------------------------
Total 1409 4386.87 $199660.09 $45.51
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 193