Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 12.86 $1607.14 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 20 22 20.66 $1001.80 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 28 36.71 $1780.64 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 15 17 17.00 $824.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 20.17 $978.09 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 84 95 112.53 $5457.67 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 12.86 $1285.71 $100.00
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Subtotal (Total Children Is Unduplicated) 115 192 240.78 $13421.80 $55.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 4.67 $233.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 3.08 $154.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 5 8.03 $401.68 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 3.00 $150.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.90 $45.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 8.71 $435.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 50 63 516.21 $25810.69 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 4.17 $208.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.57 $678.57 $50.00
INTR -INTR INTERPRETER 2 2 13.57 $678.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 120 141 1101.41 $74763.91 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 9 87.57 $4756.87 $54.32
PHY -97110 PT SESSION BY LICENSED PT 83 97 738.55 $50132.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 11 94.67 $5142.29 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 5.60 $5.60 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 1.24 $23.30 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 16.71 $835.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 191 236 1700.17 $115407.40 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.29 $450.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 17 18 159.29 $2102.57 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 156 238 6127.90 $3063.95 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 290 847 10625.32 $288230.39 $27.13
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Total 1039 10866.10 $301652.20 $27.76
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Number of Children (Unduplicated) With at Least One Authorization 299