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: 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT TRANSITION ASSESSMENT 54 55 110.00 $5500.00 $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 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 32 32 54.50 $4087.50 $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 29 29 54.00 $4050.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 8 8 10.07 $488.24 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 8.41 $840.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 143 219 396.54 $25685.54 $64.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $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 8 8 9.00 $450.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.93 $73.22 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 22 29.13 $1456.68 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.00 $75.00 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.53 $38.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 21 26.30 $1315.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.53 $88.33 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 416.00 $5200.00 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 452.14 $11303.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 153 169 1378.84 $68942.23 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 8.14 $407.15 $50.00
INTR -INTR INTERPRETER 9 9 10.00 $500.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 41 50 310.54 $21079.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 13 87.69 $4763.35 $54.32
PHY -97110 PT SESSION BY LICENSED PT 38 41 358.36 $24325.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 25.14 $1365.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 12 12.00 $12.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 59 480.42 $32610.90 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 37.72 $497.89 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 44.00 $2200.01 $50.00
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Subtotal (Total Children Is Unduplicated) 263 449 3709.77 $180250.23 $48.59
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Total 668 4106.31 $205935.77 $50.15
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Number of Children (Unduplicated) With at Least One Authorization 310