Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 11.14 $412.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 11.14 $412.29 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 88 95 107.86 $6471.43 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 15.00 $1794.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 6 11.00 $1375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 17.71 $2214.29 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 18 20 23.00 $1150.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.07 $380.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 4 6.07 $455.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 12.50 $693.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 13.14 $985.72 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 19 21.43 $1039.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 54 61 61.00 $2958.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 22 36.57 $1773.72 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 25 25.00 $1212.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 126 133 135.43 $6568.29 $48.50
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Subtotal (Total Children Is Unduplicated) 274 432 505.28 $29924.35 $59.22
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 12.00 $826.32 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 14 15 38.48 $1923.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 16.85 $842.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.60 $65.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 145 171 308.58 $15428.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 12 13.56 $338.89 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 91 167.32 $8366.23 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 5 5.93 $148.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 41 66.23 $3311.68 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 4 4.01 $100.28 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 163 200 356.79 $17839.62 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 14.93 $373.34 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.57 $482.14 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 13.14 $657.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 346 439 3761.60 $188079.87 $50.00
INTR -INTR INTERPRETER 24 30 235.76 $11787.87 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 155 195 1741.00 $118179.02 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 9 58.14 $3158.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 125 158 1227.95 $83353.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 15 105.42 $5726.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 36 42.27 $42.27 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 8 9 13.60 $254.62 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 17 94.18 $4708.83 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 243 312 2564.17 $174055.75 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.36 $291.00 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 54.29 $716.57 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 526 1017 463233.53 $231616.76 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 11 76.57 $3828.57 $50.00
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Subtotal (Total Children Is Unduplicated) 619 2824 474274.83 $876977.37 $1.85
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Total 3257 474791.24 $907314.00 $1.91
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Number of Children (Unduplicated) With at Least One Authorization 624