Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 1 1 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.64 $208.79 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 18.50 $684.50 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 4 25.14 $893.29 $35.53
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 74 78 76.21 $4572.76 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 31 31 40.14 $4801.09 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 10 10.38 $503.25 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 54 59.57 $2889.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 17 18 18.14 $879.93 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 35 35 42.29 $2050.86 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 127 132 177.71 $8619.14 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 253 368 434.45 $25256.64 $58.14
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 11 17.10 $854.77 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 15.47 $773.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 5.13 $128.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 145 163 345.48 $17274.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 12.92 $322.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 78 154.06 $7702.94 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.13 $103.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 42 81.82 $4090.84 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.02 $0.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 142 303.20 $15160.01 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.38 $159.58 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 74.29 $928.57 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 278 341 2847.62 $142381.06 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 3.00 $150.00 $50.00
INTR -INTR INTERPRETER 19 26 239.71 $11985.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 115 142 1307.63 $88761.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 14 111.79 $6072.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 102 124 851.11 $57773.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 80.04 $4347.54 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 32 32 30.50 $30.50 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 4 6 3.68 $68.85 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 33.86 $1692.85 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 182 219 1837.35 $124719.22 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.71 $147.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 16 16 123.75 $1633.50 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 404 706 135994.74 $67997.38 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 5 50.29 $2514.29 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 507 2118 144542.77 $559839.91 $3.87
-----------------------------------------------------------------------------------------------------------------------------
Total 2490 145002.35 $585989.83 $4.04
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 514