Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 6.50 $240.50 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 16.79 $621.07 $37.00
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Subtotal (Total Children Is Unduplicated) 3 4 24.29 $861.57 $35.48
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 81 84 81.20 $4871.86 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 41 42 55.00 $6578.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 10.29 $1285.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
NURS -NURS NURSING ASSESSMENT 4 4 9.60 $480.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 13 25.00 $1212.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 66 72 72.00 $3492.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 13 25.00 $1212.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 29 31 31.00 $1503.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 151 160 195.18 $9466.04 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 289 437 518.26 $31201.18 $60.20
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.14 $147.56 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 15 16 34.82 $1740.80 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 10 25.70 $1285.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 6.17 $154.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 176 211 438.59 $21929.36 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 13 18.62 $465.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 81 140.09 $7004.63 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 4 3.37 $84.31 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 52 79.72 $3986.11 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.28 $81.95 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 170 198 354.97 $17748.54 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 10.75 $268.75 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 89.29 $1116.07 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 314 397 3267.81 $163390.37 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.73 $36.67 $50.00
INTR -INTR INTERPRETER 19 24 223.95 $11197.51 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 141 181 1609.06 $109222.80 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 124.53 $6764.65 $54.32
PHY -97110 PT SESSION BY LICENSED PT 112 150 994.63 $67515.46 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 15 125.18 $6799.70 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 38 37.19 $37.19 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 9 9 11.84 $221.73 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 12 69.61 $3480.48 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 240 294 2250.20 $152743.90 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 92.43 $1220.06 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 477 904 240354.95 $120177.47 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 5 54.86 $2742.86 $50.00
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Subtotal (Total Children Is Unduplicated) 590 2660 250430.48 $703854.91 $2.81
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Total 3101 250973.02 $735917.66 $2.93
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Number of Children (Unduplicated) With at Least One Authorization 595