Summary Report for FSPSAs Ending During the Report Period Center: 03
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 2 2 4.00 $200.00 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 47 47 87.79 $6583.93 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 5.00 $375.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 29 32 32.00 $1552.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 36 36.00 $1746.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 38 44 44.00 $2134.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 31 34 34.00 $1649.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 113 135 135.00 $6547.50 $48.50
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Subtotal (Total Children Is Unduplicated) 227 340 387.79 $21384.43 $55.14
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 127 139 169.03 $8451.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 110 121 164.38 $8219.07 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 55 86.06 $4302.83 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 58 67.61 $3380.56 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 101 113 133.92 $6696.10 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 120 134 712.74 $35636.93 $50.00
INTR -INTR INTERPRETER 10 12 125.29 $6264.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 59 67 411.07 $27903.51 $67.88
PHY -97110 PT SESSION BY LICENSED PT 66 81 398.14 $27025.97 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 48 51 51.00 $51.00 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.36 $67.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 111 132 772.56 $52441.47 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 4.00 $200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 299 970 3102.16 $180759.97 $58.27
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Total 1310 3489.95 $202144.39 $57.92
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Number of Children (Unduplicated) With at Least One Authorization 351