Summary Report for FSPSAs Ending During the Report Period Center: 05
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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.00 $74.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.48 $28.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 22 23 51.00 $2550.00 $50.00
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 10 10 20.00 $1110.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 40 40 80.00 $6000.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.00 $450.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 22 22 44.00 $3300.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 40 40 80.00 $4440.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 16.00 $1200.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 30.71 $1489.64 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 17.86 $866.07 $48.50
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Subtotal (Total Children Is Unduplicated) 100 180 354.05 $21820.68 $61.63
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 16 24.00 $36000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.07 $153.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 102 181 361.90 $18095.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 84 91 184.33 $9216.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 43 94.19 $4709.52 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 60 123.17 $6158.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 77 164.59 $8229.52 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 22.82 $570.48 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 19.66 $982.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 77 80 439.52 $21976.21 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 22 22 61.76 $4192.57 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 12.43 $675.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 44 45 147.17 $9990.16 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 12.86 $698.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 22.30 $22.30 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.19 $12.47 $65.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 53 229.66 $15589.27 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.86 $263.84 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 26.86 $354.51 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 10.14 $1014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 123 152 964.10 $482.05 $0.50
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Subtotal (Total Children Is Unduplicated) 171 858 2932.59 $139937.12 $47.72
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Total 1039 3288.64 $161831.80 $49.21
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Number of Children (Unduplicated) With at Least One Authorization 198