Summary Report for FSPSAs Initiated During the Report Period Center: 57
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 10 10 3.92 $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
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Subtotal (Total Children Is Unduplicated) 12 20 12.17 $268.25 $22.05
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 7 7 6.07 $758.34 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $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 30 30 30.00 $1455.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 34 34.00 $1649.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 84 87 93.01 $4510.89 $48.50
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Subtotal (Total Children Is Unduplicated) 129 181 186.57 $10005.43 $53.63
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 132 134 191.07 $9553.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 16 16 23.20 $580.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 10.00 $500.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.60 $280.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 123 181.76 $9088.09 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 19 24.41 $610.36 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 66.07 $4850.62 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 159 162 1004.14 $50207.16 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 28 29 117.93 $8004.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 6.29 $341.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 32 32 144.50 $9808.67 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.00 $325.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 8.17 $408.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 96 99 341.85 $23204.61 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 43.64 $576.09 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.13 $213.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 182 219 5732.73 $2866.37 $0.50
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Subtotal (Total Children Is Unduplicated) 222 866 7910.49 $121420.30 $15.35
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Total 1067 8109.23 $131693.97 $16.24
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Number of Children (Unduplicated) With at Least One Authorization 232