Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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 -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 52 53 106.00 $5300.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 54 54 99.20 $7440.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 43.50 $3262.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 6.50 $487.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 48 48 87.57 $4859.95 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 38.00 $2850.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 10.57 $512.71 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 13.20 $640.20 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 16.21 $1620.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 150 237 436.75 $27919.83 $63.93
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 8 9.25 $462.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 7 6.50 $325.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 7.66 $191.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 16.88 $844.17 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 5 4.70 $117.50 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.28 $32.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 17 19.40 $970.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 13.31 $332.86 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 1103.86 $13798.21 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 128.57 $3214.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 156 180 1464.03 $73201.58 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 2 2 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 49 306.98 $20837.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 105.96 $5755.86 $54.32
PHY -97110 PT SESSION BY LICENSED PT 35 40 366.28 $24862.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 11.86 $644.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 20 29.00 $29.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.00 $200.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 63 482.81 $32773.48 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 20.36 $268.72 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 40.79 $2039.29 $50.00
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Subtotal (Total Children Is Unduplicated) 269 452 4162.63 $183283.08 $44.03
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Total 689 4599.38 $211202.91 $45.92
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Number of Children (Unduplicated) With at Least One Authorization 305