Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 12 12 9.63 $578.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.90 $42.12 $46.80
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 7 16.61 $830.72 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 22.00 $1650.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 13 13 26.00 $1950.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 14 14.00 $679.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 19.00 $921.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 31 32 43.00 $2085.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 8.00 $400.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 84 126 188.15 $11000.41 $58.47
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 3.14 $216.42 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 9.00 $619.74 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 26.07 $1303.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.50 $75.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 174 219 359.68 $17983.80 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.00 $75.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 103 158.41 $7920.52 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 104 127 203.43 $10171.47 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 135 161 231.06 $11553.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.50 $112.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 13.86 $1017.39 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 5 232.00 $5800.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 83.43 $4171.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.57 $89.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 222 271 2830.89 $141544.66 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.07 $303.34 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 9 47.91 $2395.56 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 122 152 1399.17 $94975.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 19.00 $1032.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 149 185 1923.86 $130591.49 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 38.29 $2079.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 2 2.00 $2.00 $1.00
SENS -V5264 EARMOLD 4 4 3.13 $58.66 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 5.40 $270.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 9.78 $489.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 206 252 2422.14 $164414.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 27.64 $364.89 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 9 54.00 $2700.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 384 1537 10123.43 $602368.50 $59.50
-----------------------------------------------------------------------------------------------------------------------------
Total 1664 10312.58 $613405.91 $59.48
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 393