Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 09
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 20 20 20.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 20 20 20.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.38 $12.17 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.38 $14.88 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.38 $8.23 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.38 $20.54 $54.38
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 4 2.24 $134.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.00 $717.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 6.00 $333.00 $55.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 16 28 24.76 $1517.83 $61.31
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 11 14 36.13 $1806.66 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 29 29.50 $1475.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 47 49.47 $2473.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 26 26.00 $1300.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 81 81.77 $4088.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 10.43 $765.67 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 271 368 2365.13 $118256.35 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 6.43 $321.43 $50.00
INTR -INTR INTERPRETER 4 6 22.43 $1121.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 298 439 2502.06 $169839.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 5 24.14 $1311.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 341 489 2928.00 $198752.38 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 12.86 $698.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 21 21.00 $21.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 2.68 $174.52 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 11 14 23.58 $441.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 12.43 $621.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 493 739 4725.93 $320796.37 $67.88
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Subtotal (Total Children Is Unduplicated) 799 2302 12890.96 $827907.25 $64.22
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Total 2350 12935.72 $829425.08 $64.12
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Number of Children (Unduplicated) With at Least One Authorization 799