Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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
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 -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 5 8.72 $523.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 41 42 94.00 $4700.00 $50.00
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 12 12 24.00 $1332.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 49 49 98.00 $7350.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.00 $600.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 28 28 56.00 $4200.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 51 51 102.00 $5661.00 $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 24 25 48.78 $2365.87 $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 11 11 12.00 $582.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 24 29.86 $1448.07 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 151 267 510.36 $30850.16 $60.45
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 37 53.00 $79500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 87.61 $4380.48 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 276 611 1221.90 $61095.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 280 318 644.47 $32223.33 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 133 282.46 $14122.85 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 7.00 $175.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 172 201 410.30 $20515.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 221 247 505.72 $25286.19 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.00 $150.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 7 7 78.64 $1965.95 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 150.74 $3768.58 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 20 24 239.37 $11968.59 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 13.14 $328.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 258 2281.49 $114074.32 $50.00
INTR -INTR INTERPRETER 7 8 47.43 $2371.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 52 58 288.59 $19589.34 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 42.57 $2312.47 $54.32
PHY -97110 PT SESSION BY LICENSED PT 92 110 541.77 $36775.27 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 11 50.53 $2744.96 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 53 81.30 $81.30 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 2 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.19 $12.47 $65.00
SENS -V5264 EARMOLD 5 5 13.44 $251.68 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 135 149 945.73 $64196.48 $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 12 12 90.60 $1195.92 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 23.29 $2328.58 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 296 423 6365.19 $3182.59 $0.50
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Subtotal (Total Children Is Unduplicated) 350 2708 14482.34 $506410.18 $34.97
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Total 2976 14994.70 $537334.34 $35.83
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Number of Children (Unduplicated) With at Least One Authorization 361