Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 23 25 45.00 $2250.00 $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 4 4 8.00 $600.00 $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 13 13 26.00 $1443.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 63 63 126.00 $9450.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 18 18 36.00 $2700.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 40 40 80.00 $6000.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 73 73 146.00 $8103.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.00 $450.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 36 37.00 $1794.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 43 47 49.53 $2402.37 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 169 336 578.53 $36373.37 $62.87
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 25 31.00 $46500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 7.53 $376.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 247 624 1248.00 $62400.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 265 333 666.73 $33336.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 121 146 292.00 $14600.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 157 203 408.60 $20430.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 220 271 542.00 $27100.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 7.20 $180.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 42 114.27 $2856.82 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 19 159.57 $7978.56 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 228 285 2132.11 $106605.70 $50.00
INTR -INTR INTERPRETER 7 9 24.43 $1221.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 60 75 381.44 $25891.86 $67.88
PHY -97110 PT SESSION BY LICENSED PT 119 159 801.91 $54433.64 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.64 $89.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 8 9.00 $9.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.25 $16.03 $65.00
SENS -V5264 EARMOLD 1 1 0.37 $6.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 146 178 971.02 $65912.59 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 23.57 $311.14 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 3 14.86 $1485.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 292 470 2543.29 $1271.65 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.43 $321.43 $50.00
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Subtotal (Total Children Is Unduplicated) 299 2865 10390.72 $473897.26 $45.61
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Total 3201 10969.25 $510270.62 $46.52
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Number of Children (Unduplicated) With at Least One Authorization 310