Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 1.25 $46.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 50 52 40.61 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 17 17 41.82 $1547.40 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 6 7 33.64 $1244.79 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 64 79 118.32 $2838.43 $23.99
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 51 60.71 $2944.64 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 16 16 17.00 $613.19 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 73 77 77.00 $817.74 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 75 79 78.38 $692.08 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 75 81 80.38 $868.08 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 73 77 77.38 $1686.06 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 3.38 $183.68 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 66 70 70.00 $1979.60 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 206 218 229.78 $13786.75 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 27 31 33.83 $1583.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 202 207 235.34 $28146.26 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 12.86 $1607.14 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 12 12 17.66 $2207.75 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 36 39 94.29 $11785.73 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 143 155 264.10 $13205.08 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 89 94 149.96 $7498.22 $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 23 23 33.50 $2512.50 $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 32 32 45.50 $2525.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 15 15 30.00 $1665.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 362 362 582.00 $43650.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 58 58 92.00 $6900.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 130 130 224.00 $16800.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 359 360 583.07 $32360.46 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 281 297 420.07 $31505.00 $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 90 110 128.32 $6223.40 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 562 649 708.60 $34367.01 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 103 125 148.14 $7184.93 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 493 561 588.17 $28526.12 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 12 13 13.00 $650.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1202 1377 1588.20 $77027.91 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 20.00 $2000.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 7.50 $375.00 $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) 3005 5364 6755.61 $386589.97 $57.23
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 69 83 150.40 $225600.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 98 112 286.72 $14335.85 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 479 876 1586.62 $79330.90 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 25 25 21.62 $540.42 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1440 1771 3393.28 $169663.84 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 77 84 136.67 $3416.73 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 636 800 1340.62 $67030.99 $50.00
CONOP -CONOP CONSULT, OT, PHONE 26 27 35.24 $881.04 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 561 705 1261.44 $63071.87 $50.00
CONPP -CONPP CONSULT, PT, PHONE 28 30 50.57 $1264.19 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1436 1731 3035.70 $151784.82 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 98 107 147.76 $3694.05 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 21 24 146.68 $10769.25 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 9 11 1248.57 $15607.14 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 7.20 $180.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 317 396 4026.72 $100668.11 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 7 31.36 $1567.85 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 2.00 $100.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 19 22 181.14 $9057.13 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 43.36 $1084.04 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4170 5345 39333.00 $1966649.85 $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 66 82 371.99 $18599.67 $50.00
INTR -INTR INTERPRETER 117 154 895.11 $44755.33 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1755 2318 15003.01 $1018403.97 $67.88
OCCT -97530HM OT SESSION BY OT ASST 144 158 1094.36 $59445.46 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2202 2923 18058.68 $1225823.11 $67.88
PHY -97110HM PT SESSION BY PT ASST 163 180 1226.60 $66628.91 $54.32
RSPT -RSPT RESPITE 2 2 70.93 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 467 499 701.48 $701.48 $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 16 16 21.00 $10500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 16 17 12.93 $840.55 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 10 10 17.00 $4031.04 $237.12
SENS -V5264 EARMOLD 56 67 100.91 $1889.11 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 75 87 356.34 $17817.24 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3591 4688 30177.17 $2048426.23 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 12 12 43.15 $2344.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 304 332 2619.20 $34573.46 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 12 13 60.98 $6098.08 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2968 4948 463682.45 $231841.26 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 7.60 $380.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 66 85 525.36 $26268.21 $50.00
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Subtotal (Total Children Is Unduplicated) 8161 28772 591554.63 $7709369.69 $13.03
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Total 34215 598428.57 $8098798.09 $13.53
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Number of Children (Unduplicated) With at Least One Authorization 8420