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: 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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 13 14 5.38 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 6 39.64 $1466.61 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 13.29 $491.57 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 24 28 60.30 $2032.18 $33.70
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 54 70 84.14 $4080.93 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.00 $144.28 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 54 54 55.00 $584.10 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 56 56 56.07 $495.07 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 57 58 57.93 $625.68 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 57 56.93 $1240.58 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 2.38 $129.30 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 29 29 29.00 $820.12 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 290 309 331.49 $19889.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 32 33 35.02 $1639.04 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 210 215 246.05 $29427.87 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 21 22 56.86 $7107.15 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 20 20 24.86 $3107.15 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 73 78 110.61 $5530.32 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 168 177 355.75 $17787.50 $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 33 34 45.57 $2528.95 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 11 11 21.50 $1193.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 353 353 549.20 $41190.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 74 74 133.00 $9975.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 95 95 148.00 $11100.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 318 318 483.57 $26837.95 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 252 273 389.64 $29223.22 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 5 5.14 $257.15 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 103 123 145.88 $7075.19 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 750 879 940.91 $45634.34 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 115 138 148.56 $7204.94 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 628 737 824.05 $39966.42 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 20 21 21.00 $1050.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1418 1653 1786.11 $86626.20 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 17.21 $1720.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 7 7 8.50 $425.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3427 5975 7267.15 $411290.69 $56.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 86 109 143.00 $214500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 14.17 $975.41 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 7 7 25.36 $1746.10 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 113 130 417.23 $20861.26 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 532 953 1718.03 $85901.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 29 29 17.64 $441.04 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1596 1932 3706.09 $185304.55 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 71 79 143.47 $3586.71 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 678 819 1321.00 $66050.06 $50.00
CONOP -CONOP CONSULT, OT, PHONE 19 25 33.11 $827.78 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 608 732 1275.69 $63784.27 $50.00
CONPP -CONPP CONSULT, PT, PHONE 24 24 68.54 $1713.53 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1577 1879 3315.18 $165758.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 99 109 196.56 $4914.02 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 19 20 181.57 $13330.96 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 15 16 1247.43 $15592.86 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 12.50 $312.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 379 482 3964.73 $99118.19 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 147.43 $7371.43 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 1.29 $64.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 22 23 197.90 $9895.13 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 35.29 $882.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4989 6478 47621.98 $2381099.20 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 28 32 58.04 $2902.09 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 70 109 716.88 $35843.81 $50.00
INTR -INTR INTERPRETER 178 225 1596.50 $79824.81 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1992 2687 17444.21 $1184112.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 115 122 930.40 $50539.13 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2393 3299 19932.35 $1353007.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 129 142 1063.22 $57754.34 $54.32
RSPT -RSPT RESPITE 2 2 41.60 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 649 713 783.70 $783.70 $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 13 13 19.00 $9500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 11 11 11.41 $741.54 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 18 19 29.20 $6923.90 $237.12
SENS -V5264 EARMOLD 65 75 121.76 $2279.31 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 4 4 9.23 $461.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 92 115 539.77 $26988.36 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4214 5529 35418.35 $2404197.41 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 41.14 $2234.88 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 239 273 1772.46 $23396.45 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 7 8 34.72 $3472.39 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3572 5845 761644.44 $380822.16 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 25.60 $1280.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 90 128 692.76 $34638.16 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9428 33229 908735.91 $9012336.80 $9.92
-----------------------------------------------------------------------------------------------------------------------------
Total 39232 916063.37 $9425659.68 $10.29
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 9699