Summary Report for FSPSAs Ending During the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.78 $106.67 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 20 21 40.00 $2000.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 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 -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 26.00 $1443.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 51 52 104.00 $7800.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 11 22.00 $1650.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 25 27 54.00 $4050.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 53 53 106.00 $5883.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 22.00 $1067.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 21 21 21.00 $1018.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 126 239 425.78 $27006.17 $63.43
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 12 14.00 $21000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 122 286 572.00 $28600.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 126 137 274.00 $13700.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 73 146.00 $7300.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 91 186.07 $9303.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 129 258.00 $12900.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.67 $16.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 23 45.42 $1135.44 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 8 25.29 $1264.28 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 112 122 613.84 $30691.85 $50.00
INTR -INTR INTERPRETER 5 6 12.00 $600.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 29 32 135.97 $9229.58 $67.88
PHY -97110 PT SESSION BY LICENSED PT 60 66 261.77 $17769.19 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 6.00 $6.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 80 94 368.74 $25030.23 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 5.93 $78.26 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 184 224 995.81 $497.91 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.86 $42.86 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 210 1316 3931.86 $179678.10 $45.70
-----------------------------------------------------------------------------------------------------------------------------
Total 1555 4357.64 $206684.26 $47.43
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 231