Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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 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 48 48 89.29 $6696.43 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 5.50 $305.25 $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 61 80 80.00 $3880.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 61 61.00 $2958.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 77 101 101.00 $4898.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 60 64 70.71 $3429.64 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 171 246 246.00 $11931.00 $48.50
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Subtotal (Total Children Is Unduplicated) 314 613 668.50 $35049.32 $52.43
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
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 232 296 503.28 $25164.03 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 131 247.62 $12381.11 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 96 127 196.62 $9831.06 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 204 266 430.58 $21528.88 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 253 328 2408.91 $120445.68 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.43 $121.67 $50.00
INTR -INTR INTERPRETER 16 22 403.43 $20171.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 95 136 1153.00 $78265.69 $67.88
PHY -97110 PT SESSION BY LICENSED PT 108 161 1110.75 $75397.65 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 113 133 133.00 $133.00 $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 167 240 1678.23 $113918.19 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 15.61 $780.48 $50.00
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Subtotal (Total Children Is Unduplicated) 512 1990 8459.86 $488277.09 $57.72
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Total 2603 9128.36 $523326.42 $57.33
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Number of Children (Unduplicated) With at Least One Authorization 529