Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT TRANSITION ASSESSMENT 28 28 56.00 $2800.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 43 43 82.50 $6187.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 31 31 53.50 $4012.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 12.03 $902.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 29 30 50.03 $2776.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 28 53.00 $3975.00 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 100 173 314.07 $21063.85 $67.07
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.50 $275.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.83 $20.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 7.00 $350.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 13.37 $668.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 10.17 $508.33 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 112.86 $2821.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 52 53 358.83 $17941.67 $50.00
INTR -INTR INTERPRETER 7 7 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 20 20 120.90 $8207.02 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 50.40 $2737.99 $54.32
PHY -97110 PT SESSION BY LICENSED PT 13 13 91.93 $6240.12 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 25.14 $1365.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 166.43 $11297.18 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.54 $152.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 5.00 $250.00 $50.00
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Subtotal (Total Children Is Unduplicated) 113 174 994.91 $54938.04 $55.22
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Total 347 1308.98 $76001.88 $58.06
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Number of Children (Unduplicated) With at Least One Authorization 160