Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 10.14 $375.29 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 10.14 $375.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.43 $553.58 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 40 57.50 $4312.50 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
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 23 23 25.10 $1217.58 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 23 18.44 $894.48 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 64 64 57.95 $2810.49 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 118 161 174.42 $10567.70 $60.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.40 $600.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.02 $200.84 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 6.67 $333.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 9.41 $470.72 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.40 $35.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 6.73 $336.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.67 $16.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 7.37 $368.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.68 $17.09 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 52.57 $657.14 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 179 185 1107.32 $55366.18 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 28.25 $1412.62 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 33 33 194.00 $13168.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 75.75 $4114.75 $54.32
PHY -97110 PT SESSION BY LICENSED PT 56 59 421.93 $28640.81 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 12 78.29 $4252.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 21 21.00 $21.00 $1.00
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 110 652.99 $44324.65 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 34 34 220.89 $2915.79 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 21.86 $1092.86 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 352 520 2919.20 $158633.07 $54.34
-----------------------------------------------------------------------------------------------------------------------------
Total 682 3103.77 $169576.05 $54.64
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 364