Summary Report for FSPSAs Ending During the Report Period Statewide
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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 12 13 4.54 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 8 15.64 $578.79 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 13.04 $482.32 $37.00
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Subtotal (Total Children Is Unduplicated) 24 29 34.22 $1098.11 $32.09
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 27 28.00 $1358.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 10.00 $360.70 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 64 65 65.00 $690.30 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 67 68 68.00 $600.44 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 66 67 67.00 $723.60 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 67 68 69.00 $1503.51 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 58 60 60.00 $1696.80 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 138 142 141.11 $8466.44 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 17 18 19.00 $889.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 108 110 118.69 $14195.19 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 9 9 8.80 $1100.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 18 19 45.86 $5732.15 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 54 55 64.93 $3246.75 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 90 104 188.00 $9400.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 4 4 4.00 $120.00 $30.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 2 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 17 17 28.00 $2100.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 7.50 $562.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 10 13.50 $1012.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 26 27 37.03 $2055.35 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 16 16 31.00 $1720.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 429 433 689.64 $51723.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 85 86 146.50 $10987.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 90 92 142.64 $10698.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 363 364 574.03 $31858.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 336 363 519.50 $38962.51 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 3.00 $450.00 $150.00
NURS -NURS NURSING ASSESSMENT 4 4 9.60 $480.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 59 62 60.79 $2948.26 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 314 336 360.58 $17488.10 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 50 52 56.57 $2743.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 223 228 232.01 $11252.27 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 19 21 21.00 $1050.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 624 659 721.17 $34976.73 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 8.14 $814.29 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 4.87 $243.34 $50.00
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Subtotal (Total Children Is Unduplicated) 2127 3618 4636.47 $274926.97 $59.30
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 45 48 102.00 $153000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.59 $247.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 50 56 130.26 $6512.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 366 558 916.48 $45824.21 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 10 10 8.92 $222.92 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 713 776 1215.63 $60781.70 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 32 35 46.43 $1160.78 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 325 357 534.66 $26732.81 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 9 9.23 $230.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 285 306 491.35 $24567.39 $50.00
CONPP -CONPP CONSULT, PT, PHONE 14 14 9.77 $244.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 746 820 1164.13 $58206.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 42 43 55.13 $1378.27 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 80.15 $5884.43 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 403.43 $5042.86 $12.50
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 169 189 1553.00 $38825.03 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 71.43 $3571.43 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 1.20 $60.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 10 46.29 $2314.28 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 20.43 $510.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2140 2376 13877.35 $693867.71 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 7 10.48 $524.17 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 41 53 214.05 $10702.68 $50.00
INTR -INTR INTERPRETER 91 96 432.70 $21635.25 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 998 1134 5464.07 $370901.14 $67.88
OCCT -97530HM OT SESSION BY OT ASST 63 65 297.66 $16169.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1136 1278 5811.25 $394467.47 $67.88
PHY -97110HM PT SESSION BY PT ASST 79 81 386.70 $21005.44 $54.32
RSPT -RSPT RESPITE 1 1 48.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 234 245 318.19 $318.19 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 11.00 $5500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 5.07 $329.81 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 28 31 47.00 $879.78 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 44 49 115.24 $5761.79 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1995 2270 11082.60 $752286.71 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.70 $146.41 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 126 131 882.29 $11646.27 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 3.00 $300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1705 2373 170356.14 $85178.07 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 6.50 $325.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 43 57 278.37 $13918.69 $50.00
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Subtotal (Total Children Is Unduplicated) 4877 13528 216525.07 $2843569.58 $13.13
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Total 17175 221195.75 $3119594.66 $14.10
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Number of Children (Unduplicated) With at Least One Authorization 5627