Summary Report for FSPSAs Initiated During the Report Period Statewide
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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 1.25 $46.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 18 18 13.92 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 16 16 29.54 $1092.82 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 18.79 $695.07 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 29 41 64.49 $1834.15 $28.44
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 28 35.71 $1732.14 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 72 76 76.00 $807.12 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 72 76 75.38 $665.59 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 73 79 78.38 $846.48 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 72 76 76.38 $1664.27 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 2.38 $129.30 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 65 69 69.00 $1951.32 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 115 119 123.55 $7412.75 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 17 18.00 $842.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 109 110 135.26 $16176.95 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 8 10.50 $1311.91 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 11 37.71 $4714.29 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 36 37 40.05 $2002.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 75 79 123.96 $6198.22 $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 1 2 2.00 $150.00 $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 3 3 5.00 $375.00 $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 7 8 12.50 $937.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 29 42.50 $2358.75 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 18.00 $999.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 339 339 537.00 $40275.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 52 52 80.00 $6000.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 115 115 194.00 $14550.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 335 336 536.07 $29751.96 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 277 293 413.57 $31017.50 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 44 49 48.30 $2342.48 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 294 318 336.67 $16328.56 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 54 59 70.29 $3408.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 244 261 255.01 $12368.20 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 11 11 11.00 $550.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 603 632 657.56 $31891.52 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 6.50 $325.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 1867 3346 4178.72 $243592.90 $58.29
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 43 49 111.40 $167100.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 49 51 117.75 $5887.42 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 345 497 822.58 $41129.23 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 21 21 16.28 $407.09 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 655 683 1071.41 $53570.66 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 33 34 39.86 $996.43 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 297 322 452.86 $22643.13 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 6 6.19 $154.79 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 272 287 451.42 $22570.86 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 9 11.18 $279.55 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 647 690 970.59 $48529.61 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 46 48 51.97 $1299.26 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 74.78 $5490.42 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 764.71 $9558.93 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.60 $65.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 174 184 1821.86 $45546.50 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 18.21 $910.71 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 18.00 $900.01 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 4.79 $119.76 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2129 2318 12871.82 $643590.89 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 10 11 39.71 $1985.63 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 38 44 138.42 $6920.88 $50.00
INTR -INTR INTERPRETER 77 90 419.46 $20973.10 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 882 998 4735.62 $321453.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 57 58 423.81 $23021.47 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1110 1253 5911.41 $401266.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 62 65 400.64 $21762.92 $54.32
RSPT -RSPT RESPITE 2 2 70.93 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 214 219 225.86 $225.86 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 9.00 $4500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.00 $390.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 31 32 52.83 $988.91 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 33 36 113.35 $5667.25 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1845 2076 10119.74 $686928.00 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 12.15 $660.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 145 147 1120.52 $14790.85 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 17.35 $1734.76 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1626 2300 163537.93 $81768.96 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 7.60 $380.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 33 34 193.27 $9663.34 $50.00
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Subtotal (Total Children Is Unduplicated) 4564 12621 207263.86 $2677541.89 $12.92
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Total 16008 211507.07 $2922968.94 $13.82
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Number of Children (Unduplicated) With at Least One Authorization 4876