Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 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
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT TRANSITION ASSESSMENT 5 5 10.00 $500.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 32 32 52.50 $3937.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 26.50 $1987.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 34 34 56.00 $3108.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 10.50 $787.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 30 31 31.00 $1503.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 33 33.00 $1600.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 40 43 43.00 $2085.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 26 26.00 $1261.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 102 109 109.00 $5286.50 $48.50
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Subtotal (Total Children Is Unduplicated) 189 338 403.50 $22429.50 $55.59
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 114 163.00 $8150.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 110 113 177.28 $8863.84 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 41 69.34 $3466.90 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 51 85.90 $4294.96 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 101 105 151.41 $7570.38 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 122 131 776.17 $38808.32 $50.00
INTR -INTR INTERPRETER 11 13 140.75 $7037.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 58 61 386.86 $26260.16 $67.88
PHY -97110 PT SESSION BY LICENSED PT 66 70 512.59 $34794.62 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 55 56 56.00 $56.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 102 109 706.29 $47943.00 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 9.14 $457.15 $50.00
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Subtotal (Total Children Is Unduplicated) 292 867 3236.72 $187752.81 $58.01
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Total 1205 3640.22 $210182.31 $57.74
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Number of Children (Unduplicated) With at Least One Authorization 299