Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 11.14 $412.29 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 11.14 $412.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 8.43 $505.72 $60.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.43 $553.58 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 16.57 $2071.44 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
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 30 41 59.00 $4425.00 $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 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 44 49 47.06 $2282.42 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 53 37.78 $1832.41 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 134 141 136.11 $6601.11 $48.50
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Subtotal (Total Children Is Unduplicated) 211 308 326.38 $19190.71 $58.80
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.40 $3600.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 5.02 $250.84 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 9 9 29.02 $1450.78 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.85 $46.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 21 41.27 $2063.57 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.97 $124.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 21 41.75 $2087.45 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 5.78 $144.59 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 21 26.85 $1342.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 6 8.02 $200.42 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 5 77.86 $973.21 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.86 $321.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 440 3193.39 $159669.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 12 92.71 $4635.71 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 79 90 689.36 $46793.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 29 33 209.96 $11405.27 $54.32
PHY -97110 PT SESSION BY LICENSED PT 117 143 1204.76 $81779.16 $67.88
PHY -97110HM PT SESSION BY PT ASST 29 38 273.97 $14881.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 42 43 65.44 $65.44 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 3 3 7.00 $131.04 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 227 270 2090.88 $141928.88 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 13.86 $752.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 69 76 600.96 $7932.72 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 49.07 $2453.58 $50.00
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Subtotal (Total Children Is Unduplicated) 675 1263 8756.00 $487434.81 $55.67
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Total 1573 9093.52 $507037.81 $55.76
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Number of Children (Unduplicated) With at Least One Authorization 687