Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
EXIT -EXIT TRANSITION ASSESSMENT 14 14 27.00 $1350.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 2 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 1.53 $85.10 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 52 52 92.50 $6937.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 35 58.50 $4387.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 16.00 $1200.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 58 58 99.53 $5524.10 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 38.00 $2850.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 7.00 $339.50 $48.50
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Subtotal (Total Children Is Unduplicated) 108 206 349.57 $23220.58 $66.43
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 7.00 $350.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 7 8.08 $404.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.96 $74.11 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.00 $50.00 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.22 $5.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 9 8.70 $435.24 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 3.38 $84.53 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 351.43 $4392.86 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 132.14 $3303.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 46 233.87 $11693.35 $50.00
INTR -INTR INTERPRETER 2 2 6.71 $335.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 18 18 138.00 $9367.44 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 12.64 $686.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 15 15 84.69 $5748.71 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 9.29 $504.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.00 $10.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 24 120.07 $8150.45 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 168.18 $2219.92 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.98 $198.81 $50.00
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Subtotal (Total Children Is Unduplicated) 106 169 1305.34 $49565.43 $37.97
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Total 376 1656.91 $72786.01 $43.93
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Number of Children (Unduplicated) With at Least One Authorization 198