Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.14 $517.86 $125.00
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 2.00 $111.00 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 27 30 27.46 $1331.87 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 29 41.00 $1988.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 20 19.51 $946.02 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 15 44.86 $2175.57 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 76 85 105.53 $5118.06 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 7.14 $714.29 $100.00
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Subtotal (Total Children Is Unduplicated) 116 191 263.64 $13765.44 $52.21
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 17.33 $866.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 5 3.59 $179.59 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 6.82 $341.25 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 5.35 $267.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.20 $60.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 20.86 $1042.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 58 76 516.21 $25810.36 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 14.01 $700.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 275.57 $13778.57 $50.00
INTR -INTR INTERPRETER 3 4 19.86 $992.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 128 161 1144.76 $77706.17 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 71.50 $3883.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 79 94 777.36 $52767.52 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 11 93.71 $5090.56 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.33 $4.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 2 2 4.36 $81.54 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 15.29 $764.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 240 290 2100.86 $142606.18 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 23 23 195.29 $2577.77 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 227 338 3386.29 $1693.15 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 20.57 $1028.57 $50.00
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Subtotal (Total Children Is Unduplicated) 355 1047 8706.12 $337342.61 $38.75
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Total 1238 8969.76 $351108.05 $39.14
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Number of Children (Unduplicated) With at Least One Authorization 363