Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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 22 24 10.61 $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) 24 34 18.86 $268.25 $14.23
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 11.00 $396.77 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 12.86 $1607.14 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 11 11 13.23 $1654.18 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 10.00 $1250.00 $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 48 54 84.14 $4080.93 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 71 82 82.00 $3977.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 185 213 231.87 $11245.46 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.14 $614.29 $100.00
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Subtotal (Total Children Is Unduplicated) 269 408 476.74 $26691.76 $55.99
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 9.00 $450.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 326 389 782.63 $39131.44 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 36 38 72.47 $1811.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 19.60 $980.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 12.57 $628.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 312 370 754.19 $37709.52 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 35 38 62.31 $1557.86 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 12 123.21 $9046.03 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.14 $278.57 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.86 $321.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 375 458 3920.71 $196035.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 54 333.14 $22613.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 9.79 $531.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 72 79 492.79 $33450.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 11 45.57 $2475.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 11 60.59 $3029.28 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 182 203 989.42 $67161.84 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 20 20 83.00 $1095.60 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.13 $213.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 419 597 13176.64 $6588.32 $0.50
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Subtotal (Total Children Is Unduplicated) 487 2313 20974.75 $425110.73 $20.27
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Total 2755 21470.34 $452070.74 $21.06
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Number of Children (Unduplicated) With at Least One Authorization 501