Summary Report for FSPSAs Ending During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 7 7 3.19 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 9 9 7.25 $268.25 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 14 17 11.44 $268.25 $23.45
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 6.00 $216.42 $36.07
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 2.17 $270.84 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 2 2 2.00 $60.00 $30.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 7.50 $562.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 17 47.14 $2286.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 26 26.00 $1261.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 67 75 76.00 $3686.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.14 $614.29 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 105 143 180.95 $9802.18 $54.17
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 121 144 230.20 $11510.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 13 20.33 $508.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.60 $130.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 3.97 $198.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 137 216.87 $10843.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 14 22.90 $572.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 18.57 $1363.51 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.14 $278.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 148 175 1194.14 $59707.11 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 12 12 58.64 $3980.69 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.50 $190.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 16 17 91.14 $6186.78 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 26.71 $1451.12 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 33.13 $1656.66 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 50 225.14 $15282.67 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 7.21 $95.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 165 221 2818.00 $1409.00 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 196 816 4989.22 $115613.95 $23.17
-----------------------------------------------------------------------------------------------------------------------------
Total 976 5181.61 $125684.38 $24.26
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 213