Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 7.14 $264.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 7.14 $264.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 11.00 $660.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 3 3 4.25 $212.50 $50.00
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 23 23 35.50 $2662.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 16 25.50 $1415.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 33 46 72.50 $5437.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 7.00 $509.46 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 65 71 87.16 $4227.20 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 10 9.51 $461.29 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 50 56 50.43 $2445.99 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 156 172 146.76 $7117.75 $48.50
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Subtotal (Total Children Is Unduplicated) 277 424 461.61 $25931.93 $56.18
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 3.07 $153.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 2.45 $61.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 17 13.05 $652.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 10.33 $258.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 23 18.99 $949.65 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.85 $121.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 20 17.22 $860.84 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 7 26.08 $651.91 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 25 32.76 $1637.98 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 11 11 32.73 $818.16 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 131.43 $1642.86 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 439 539 4299.01 $214950.63 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 69.10 $3455.01 $50.00
INTR -INTR INTERPRETER 1 1 2.73 $136.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 91 115 822.50 $55831.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 21 25 183.49 $9967.21 $54.32
PHY -97110 PT SESSION BY LICENSED PT 102 125 1005.96 $68284.47 $67.88
PHY -97110HM PT SESSION BY PT ASST 27 29 234.82 $12755.51 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 64 70 77.33 $77.33 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 250 307 2481.22 $168425.01 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 21.29 $1156.24 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 51 58 524.86 $6928.12 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 9 9 863.00 $431.50 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 7 63.17 $3158.58 $50.00
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Subtotal (Total Children Is Unduplicated) 754 1430 10957.57 $560087.82 $51.11
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Total 1855 11426.33 $586284.04 $51.31
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Number of Children (Unduplicated) With at Least One Authorization 769