Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 23 24 10.43 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 10 12 39.73 $1470.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 20.54 $759.82 $37.00
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Subtotal (Total Children Is Unduplicated) 38 46 71.70 $2266.96 $31.62
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 58 62 75.00 $3637.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 11.00 $396.77 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 65 66 66.00 $700.92 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 69 71 70.51 $622.56 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 69 71 70.51 $761.46 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 70 71 71.51 $1558.11 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 2.51 $136.25 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 60 62 62.00 $1753.36 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.00 $63.62 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 276 289 291.27 $17476.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 33 35 35.90 $1680.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 216 225 256.80 $30713.27 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 20 20 26.09 $3260.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 30 32 70.57 $8821.44 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 109 119 201.01 $10050.64 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 132 146 265.00 $13250.00 $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 31 32 43.07 $2390.20 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 18 18 35.00 $1942.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 454 458 737.64 $55323.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 93 94 162.50 $12187.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 112 114 186.64 $13998.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 397 398 665.03 $36909.35 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 341 368 528.50 $39637.51 $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
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 106 130 151.46 $7345.87 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 679 784 870.75 $42231.31 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 108 129 157.08 $7618.23 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 544 613 689.62 $33446.78 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 25 28 28.00 $1400.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1354 1529 1700.04 $82451.95 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 5 5 15.25 $1525.25 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 10 10 13.37 $668.34 $50.00
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Subtotal (Total Children Is Unduplicated) 3455 6049 7641.22 $439480.25 $57.51
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 80 101 165.00 $247500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 3 4.15 $286.04 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 13.14 $905.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 106 125 321.73 $16086.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 539 1018 1847.90 $92395.04 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 17 17 17.95 $448.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1575 1977 3745.72 $187285.94 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 76 89 156.60 $3915.10 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 662 826 1396.55 $69827.31 $50.00
CONOP -CONOP CONSULT, OT, PHONE 18 23 28.91 $722.64 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 609 774 1423.49 $71174.40 $50.00
CONPP -CONPP CONSULT, PT, PHONE 28 28 40.01 $1000.31 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1593 1976 3408.20 $170409.85 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 94 101 185.36 $4633.88 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 23 24 200.43 $14715.81 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 15 15 1609.57 $20119.64 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 3.70 $92.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 332 415 3732.46 $93311.55 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 109.43 $5471.43 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 2.20 $110.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 18 18 133.86 $6692.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 22.57 $564.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4719 6052 45505.52 $2275275.93 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 22 23 50.67 $2533.62 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 70 105 689.50 $34474.80 $50.00
INTR -INTR INTERPRETER 163 192 1298.73 $64936.65 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1966 2607 16691.70 $1133032.32 $67.88
OCCT -97530HM OT SESSION BY OT ASST 125 139 966.30 $52489.63 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2365 3115 19827.92 $1345919.38 $67.88
PHY -97110HM PT SESSION BY PT ASST 154 172 1103.14 $59922.61 $54.32
RSPT -RSPT RESPITE 2 2 97.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 553 613 712.76 $712.76 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 13 19.00 $9500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 12 13 11.32 $736.01 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 13 13 22.00 $5216.64 $237.12
SENS -V5264 EARMOLD 58 64 103.67 $1940.64 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 5.45 $272.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 95 114 470.44 $23521.90 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4072 5257 33976.38 $2306316.86 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 7 30.76 $1670.99 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 271 293 2331.07 $30770.17 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 32.03 $3203.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3479 5785 608027.28 $304013.63 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 7.10 $355.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 78 123 584.47 $29223.46 $50.00
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Subtotal (Total Children Is Unduplicated) 9172 32260 751133.22 $8693707.74 $11.57
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Total 38355 758846.14 $9135454.94 $12.04
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Number of Children (Unduplicated) With at Least One Authorization 9467