Summary Report for FSPSAs Initiated During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5 2.36 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 10 22.09 $817.35 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 2.75 $101.75 $37.00
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Subtotal (Total Children Is Unduplicated) 15 21 27.20 $919.10 $33.80
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 27 27.00 $1309.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $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) 66 67 67.00 $591.61 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 65 66 66.00 $712.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 67 68 68.00 $1481.72 $21.79
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 -AUDE UNSPECIFIED AUDE SERVICES 164 167 169.20 $10152.28 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 19 19 18.90 $884.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 103 104 114.73 $13722.10 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 7 7 13.29 $1660.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 15 15 26.71 $3339.29 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 26 26 30.33 $1516.39 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 104 117 214.50 $10725.00 $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 16 16 26.00 $1950.00 $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 9 9 11.50 $862.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 29 39.07 $2168.20 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 25.00 $1387.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 427 431 686.64 $51498.22 $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 97 98 155.64 $11673.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 368 369 584.03 $32413.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 336 362 519.50 $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
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 61 63 61.51 $2983.02 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 355 384 402.88 $19539.54 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 57 60 60.00 $2910.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 246 258 282.28 $13690.71 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 20 20 20.00 $1000.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 647 699 729.01 $35356.92 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 7.11 $710.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 4.50 $225.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2103 3731 4724.34 $278289.20 $58.91
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 49 56 84.00 $126000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.71 $255.44 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 13.14 $905.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 55 57 112.82 $5640.83 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 385 550 906.80 $45339.77 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 11 6.72 $167.92 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 745 779 1289.43 $64471.66 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 35 36 61.94 $1548.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 313 329 487.88 $24394.02 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 9 9.31 $232.71 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 290 310 500.32 $25015.82 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 9 11.60 $290.03 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 774 816 1219.10 $60955.18 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 33 34 53.28 $1331.88 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 66.14 $4856.20 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 803.14 $10039.29 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 138 160 906.08 $22651.92 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 12.00 $600.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.32 $16.11 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 22.57 $1128.58 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.14 $53.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2360 2576 15007.78 $750389.09 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 12 11.07 $553.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 35 47 398.96 $19948.12 $50.00
INTR -INTR INTERPRETER 99 105 524.53 $26226.53 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1002 1142 5575.62 $378472.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 50 51 288.26 $15658.50 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1144 1296 6264.03 $425202.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 62 64 339.41 $18436.98 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 258 263 260.32 $260.32 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 5.00 $325.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 9 14.00 $3319.68 $237.12
SENS -V5264 EARMOLD 29 29 43.63 $816.82 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 5.45 $272.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 54 55 213.09 $10654.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2067 2349 11856.86 $804843.35 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 21.00 $1140.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 97 101 665.56 $8785.44 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1827 2615 226003.86 $113001.93 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.60 $30.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 50 66 216.47 $10823.46 $50.00
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Subtotal (Total Children Is Unduplicated) 5021 13980 274293.95 $2987656.23 $10.89
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Total 17732 279045.48 $3266864.53 $11.71
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Number of Children (Unduplicated) With at Least One Authorization 5338