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: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 1.87 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 9.43 $348.86 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 10.43 $385.86 $37.00
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Subtotal (Total Children Is Unduplicated) 9 10 23.73 $808.72 $34.08
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 32 36 49.43 $2397.29 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 53 53 54.00 $573.48 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 53 53 54.00 $476.82 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 54 54 54.87 $592.56 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 54 54 54.87 $1195.55 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.31 $71.30 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 27 27 27.00 $763.56 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 150 154 171.86 $10311.82 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 18.00 $842.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 98 99 117.91 $14101.99 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 9 10 32.71 $4089.29 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 13.86 $1732.15 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 16 18 17.53 $876.67 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 129 137 258.75 $12937.50 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 3 3 3.00 $90.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.00 $225.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 22 22 34.00 $2550.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 17.00 $1275.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 4.87 $365.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 19 20 25.37 $1902.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 28 37.50 $2081.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 17.50 $971.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 328 328 501.20 $37590.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 66 66 117.00 $8775.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 74 74 107.00 $8025.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 285 285 418.57 $23230.45 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 248 269 381.64 $28623.22 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.14 $57.15 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 50 51 51.00 $2473.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 374 417 451.24 $21885.12 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 60 60 59.47 $2884.40 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 304 340 350.28 $16988.62 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 13 14 14.00 $700.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 683 760 819.60 $39750.40 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 2032 3491 4348.48 $251781.72 $57.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 49 56 80.00 $120000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 7.07 $486.94 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 58 61 192.00 $9600.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 368 494 785.29 $39264.53 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 22 22 10.08 $251.88 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 656 695 1129.45 $56472.59 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 25 25 33.30 $832.59 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 310 336 447.29 $22364.36 $50.00
CONOP -CONOP CONSULT, OT, PHONE 11 11 14.00 $350.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 243 251 380.37 $19018.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 8 16.08 $401.94 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 649 692 1005.83 $50291.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 51 51 66.31 $1657.79 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 46.86 $3440.25 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 82.00 $1025.00 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 9.00 $225.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 210 252 1715.59 $42889.69 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 126.57 $6328.57 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 0.29 $14.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 13 86.76 $4337.98 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 22.14 $553.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2417 2755 15629.54 $781477.02 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 12 22.95 $1147.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 47 60 247.18 $12358.84 $50.00
INTR -INTR INTERPRETER 111 127 691.02 $34550.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 992 1173 5826.45 $395499.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 51 52 309.51 $16812.31 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1183 1394 6192.58 $420352.13 $67.88
PHY -97110HM PT SESSION BY PT ASST 59 60 322.92 $17540.86 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 312 317 329.05 $329.05 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 4.00 $6600.00 $1650.00
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 4 4 5.16 $335.15 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 10 10 15.20 $3604.22 $237.12
SENS -V5264 EARMOLD 39 41 61.33 $1148.16 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 4.63 $231.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 40 50 160.09 $8004.53 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2090 2441 11886.84 $806878.47 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 20.14 $1094.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 124 130 738.46 $9747.64 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 20.71 $2071.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1765 2381 271393.72 $135696.85 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 23.80 $1190.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 46 60 265.07 $13253.37 $50.00
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Subtotal (Total Children Is Unduplicated) 5056 14083 320453.62 $3055230.91 $9.53
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Total 17584 324825.83 $3307821.35 $10.18
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Number of Children (Unduplicated) With at Least One Authorization 5390