Summary Report for FSPSAs Initiated During the Report Period Center: 51
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 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 2.39 $143.33 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.50 $125.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 7.00 $525.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.00 $300.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 6 11.00 $825.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.00 $388.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 13.14 $637.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 11.00 $533.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 33 53 79.03 $4507.76 $57.04
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 8.93 $446.43 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 71 73 111.65 $5582.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.50 $37.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 32 45.24 $2262.23 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 37 59.23 $2961.71 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 43 46 66.31 $3315.28 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.00 $75.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 8.71 $639.80 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.86 $142.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.86 $96.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 102 104 748.93 $37446.66 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 2.33 $116.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 12.08 $604.05 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 51 51 323.47 $21956.92 $67.88
PHY -97110 PT SESSION BY LICENSED PT 59 61 531.21 $36058.26 $67.88
SENS -V5264 EARMOLD 2 2 1.11 $20.80 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.33 $116.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 85 577.88 $39226.40 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 27.29 $1364.29 $50.00
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Subtotal (Total Children Is Unduplicated) 181 512 2541.42 $152607.93 $60.05
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Total 566 2621.45 $157152.69 $59.95
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Number of Children (Unduplicated) With at Least One Authorization 188