Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 7.00 $420.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 13.71 $1714.29 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 3.00 $150.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 4 7.50 $562.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 40 62 100.50 $7537.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 53 57 56.57 $2743.77 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 49 56 53.73 $2606.10 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 145 157 144.14 $6990.57 $48.50
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Subtotal (Total Children Is Unduplicated) 231 364 406.16 $23784.30 $58.56
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 7.97 $398.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 13 22.89 $1144.61 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 27 53.93 $2696.43 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 23 38.20 $1909.88 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 7.25 $181.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 25 34.15 $1707.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 7.58 $189.58 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 116.00 $1450.00 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.71 $117.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 401 474 3798.72 $189935.80 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 77.32 $3865.96 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 93 120 922.71 $62633.85 $67.88
OCCT -97530HM OT SESSION BY OT ASST 23 29 177.81 $9658.45 $54.32
PHY -97110 PT SESSION BY LICENSED PT 129 156 1478.05 $100330.03 $67.88
PHY -97110HM PT SESSION BY PT ASST 30 37 242.36 $13164.85 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 60 62 81.89 $81.89 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 4 4 4.36 $81.54 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 262 310 2494.54 $169329.61 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 18.71 $1016.56 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 59 67 523.64 $6912.09 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 66.10 $3305.24 $50.00
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Subtotal (Total Children Is Unduplicated) 751 1398 10186.40 $570924.05 $56.05
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Total 1762 10592.55 $594708.36 $56.14
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Number of Children (Unduplicated) With at Least One Authorization 765