Summary Report for FSPSAs Ending During the Report Period Statewide
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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 34 34 32.19 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 15 24.04 $889.32 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 4.00 $148.00 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 48 54 61.47 $1046.57 $17.02
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 17 19.00 $921.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 9.00 $324.63 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 72 76 76.00 $807.12 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 71 75 75.00 $662.25 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 70 76 76.00 $820.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 70 74 74.00 $1612.46 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 68 68.00 $1923.04 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 102 105 104.93 $6295.61 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 15 16.83 $787.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 89 91 104.65 $12516.06 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 6.60 $824.41 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 20 21 38.71 $4839.30 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 61 64 68.27 $3413.30 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 64 68 104.46 $5223.22 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 2 2 2.00 $60.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 3.00 $225.00 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 22 22 31.50 $2362.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 8.00 $600.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 10.50 $787.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 29 41.50 $2303.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 11 11 22.00 $1221.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 341 341 543.00 $40725.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 53 53 82.00 $6150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 119 119 203.00 $15225.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 338 339 527.50 $29276.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 278 293 414.07 $31055.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 47 51 57.82 $2804.15 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 267 281 322.67 $15649.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 57 62 62.00 $3007.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 229 242 252.73 $12257.29 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 5 5 5.00 $250.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 572 611 696.71 $33790.29 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.14 $614.29 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1859 3246 4142.58 $240000.29 $57.94
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 36 40 71.40 $107100.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 45 46 71.30 $3565.09 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 309 424 695.23 $34761.73 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 17 17 11.08 $277.09 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 609 671 1088.59 $54429.53 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 35 36 53.68 $1342.03 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 310 339 482.24 $24111.91 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 14 15.20 $380.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 247 266 417.17 $20858.37 $50.00
CONPP -CONPP CONSULT, PT, PHONE 12 12 18.39 $459.65 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 604 663 989.68 $49483.87 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 43 44 54.47 $1361.76 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 12 33.33 $2446.92 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 98.14 $1226.79 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 1.60 $40.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 136 149 954.95 $23873.80 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 13.14 $657.14 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 8 47.43 $2371.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1871 2074 11758.53 $587926.54 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 10.10 $505.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 23 27 101.37 $5068.29 $50.00
INTR -INTR INTERPRETER 60 72 305.65 $15282.73 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 851 955 4762.83 $323300.66 $67.88
OCCT -97530HM OT SESSION BY OT ASST 70 72 396.79 $21553.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1105 1226 5867.46 $398283.19 $67.88
PHY -97110HM PT SESSION BY PT ASST 65 70 370.39 $20119.49 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 178 182 261.47 $261.47 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 7.00 $3500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 9 6.44 $418.49 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 11.00 $2608.32 $237.12
SENS -V5264 EARMOLD 30 32 39.09 $731.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 30 33 118.20 $5910.11 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1739 1976 9856.81 $669080.32 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 13.28 $721.17 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 134 145 860.73 $11361.59 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 26.78 $2677.61 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1458 1996 139006.27 $69503.13 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 29 32 100.19 $5009.64 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4351 11679 178998.39 $2474220.34 $13.82
-----------------------------------------------------------------------------------------------------------------------------
Total 14979 183202.44 $2715267.20 $14.82
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 5019