Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 22 22 43.00 $2150.00 $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 11 11 20.00 $1500.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 59 59 125.53 $6967.10 $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 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 14.00 $679.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 6.11 $610.96 $100.00
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Subtotal (Total Children Is Unduplicated) 128 235 417.68 $27173.54 $65.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
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 4 5 8.66 $216.51 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.40 $170.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 6 8.03 $200.83 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.22 $5.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 18 19.74 $986.90 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 14.16 $354.11 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 8 8 1404.29 $17553.57 $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 136 158 1256.86 $62842.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 5.14 $257.15 $50.00
INTR -INTR INTERPRETER 2 2 6.71 $335.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 47 51 408.35 $27718.95 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 15 94.73 $5145.91 $54.32
PHY -97110 PT SESSION BY LICENSED PT 40 42 473.53 $32142.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 4 41.14 $2234.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 19 28.00 $28.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 13.00 $650.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 65 550.14 $37343.69 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 202.13 $2668.09 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 7 19.05 $952.38 $50.00
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Subtotal (Total Children Is Unduplicated) 261 448 4707.51 $198915.65 $42.25
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Total 684 5127.19 $226089.18 $44.10
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Number of Children (Unduplicated) With at Least One Authorization 296