Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 28.73 $1063.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 2.75 $101.75 $37.00
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Subtotal (Total Children Is Unduplicated) 9 10 31.48 $1164.89 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 13 14.00 $679.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.00 $43.58 $21.79
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 55 57 56.94 $3416.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 15 19.00 $2272.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 4.75 $237.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 55 68 121.00 $6050.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 20.50 $1537.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 6.50 $487.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 11.50 $862.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 18 25.53 $1417.10 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 284 286 417.14 $31285.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 35.50 $2662.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 53 53 66.64 $4998.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 217 218 310.50 $17232.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 250 255 334.50 $25087.51 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 3.00 $450.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 13.00 $630.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 11.29 $547.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 38.00 $1843.00 $48.50
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Subtotal (Total Children Is Unduplicated) 565 1076 1531.30 $102592.94 $67.00
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 16 17.00 $25500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 16.00 $800.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 71 89.78 $4488.93 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 7 3.75 $93.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 36 42.00 $2100.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 14 22.40 $560.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 6 8.57 $428.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.27 $131.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 27 29.54 $1477.03 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 9 14.43 $360.84 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 39 54.33 $2716.66 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 27 40.78 $1019.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 32 37 1008.34 $25208.57 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 26.00 $1300.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 594 693 5084.81 $254240.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 29.03 $1451.67 $50.00
INTR -INTR INTERPRETER 95 109 746.21 $37310.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 88 112 887.69 $60256.42 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 45.71 $2483.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 192 242 1904.61 $129285.10 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 9 71.79 $3899.40 $54.32
RSPT -RSPT RESPITE 2 2 97.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 67 71 150.35 $150.35 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 5 5 10.26 $192.05 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 43.22 $2161.19 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 549 677 5565.86 $377810.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 30 31 230.82 $3046.84 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 13.00 $1300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 968 1683 11567.70 $5783.85 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 53.86 $2692.86 $50.00
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Subtotal (Total Children Is Unduplicated) 1150 3964 27888.18 $950672.33 $34.09
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Total 5050 29450.97 $1054430.16 $35.80
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Number of Children (Unduplicated) With at Least One Authorization 1258