Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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 1 2 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 2 2.00 $74.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 16 14.79 $887.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.08 $9.30 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 3 11.50 $575.00 $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 10 10 10.00 $485.00 $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 15 16 16.00 $776.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 32 34 110.14 $5341.93 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 70 102 209.65 $11081.00 $52.85
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 39.14 $1957.14 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 164 197 332.48 $16624.08 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.00 $75.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 99 156.33 $7816.75 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 96 113 167.32 $8365.88 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.00 $75.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 132 201.80 $10090.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.00 $75.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 5 11.71 $860.06 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 7.43 $371.43 $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 208 253 2625.89 $131294.70 $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 6 6 28.51 $1425.48 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 117 151 1462.52 $99276.03 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.29 $124.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 141 177 1832.85 $124413.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 62.29 $3383.36 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -V5264 EARMOLD 5 5 3.19 $59.70 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 17.78 $889.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 192 234 2254.57 $153040.18 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 32.57 $429.94 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 11 61.57 $3078.57 $50.00
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Subtotal (Total Children Is Unduplicated) 373 1418 9320.44 $564090.57 $60.52
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Total 1522 9532.09 $575245.57 $60.35
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Number of Children (Unduplicated) With at Least One Authorization 381