Summary Report for FSPSAs Ending During the Report Period Statewide
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 0.56 $0.00 $0.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 25.50 $943.50 $37.00
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Subtotal (Total Children Is Unduplicated) 7 7 28.06 $1017.50 $36.27
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 28 31.71 $1538.14 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 51 52 52.00 $552.24 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 52 53 53.00 $467.99 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 52 53 53.00 $572.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 53 53.00 $1154.87 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 47 47.00 $1329.16 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 155 160 165.54 $9932.20 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 14 13.33 $624.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 90 90 95.69 $11444.39 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 9 14.00 $1750.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 16.29 $2035.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 26 26 27.02 $1351.04 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 148 160 304.29 $15214.29 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 24 24 41.50 $3112.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 9.00 $675.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 11.50 $862.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 21 33.00 $2475.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 36 36 55.80 $3096.90 $55.50
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 337 337 593.00 $44475.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 127 127 225.29 $16896.43 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 62 62 109.96 $8247.14 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 286 288 501.96 $27858.89 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 264 277 460.21 $34516.07 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 7.00 $509.46 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 49 53 59.23 $2872.43 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 416 453 482.42 $23397.51 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 55 64 66.43 $3221.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 323 338 357.05 $17316.74 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 23 23 23.00 $1150.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 781 855 867.04 $42051.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 9.41 $940.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2273 3751 4866.66 $283046.71 $58.16
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 57 66 105.00 $157500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 10.37 $713.85 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 13.00 $895.18 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 57 59 133.75 $6687.58 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 352 455 706.01 $35300.71 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 34 37 23.88 $597.03 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 721 774 1159.94 $57996.99 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 30 32 33.20 $829.96 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 315 335 449.16 $22458.15 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 10 8.70 $217.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 270 289 406.76 $20337.81 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 7 6.41 $160.37 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 742 790 1082.49 $54124.57 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 44 48 55.53 $1388.34 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 68.86 $5055.49 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 395.14 $4939.28 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 172 186 1267.66 $31691.55 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.43 $321.43 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 26.80 $1340.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 21.14 $528.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2386 2632 15055.71 $752785.65 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 16 17 29.30 $1465.14 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 32 33 160.60 $8029.76 $50.00
INTR -INTR INTERPRETER 132 141 582.31 $29115.49 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1056 1196 5788.24 $392905.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 50 53 260.27 $14138.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1236 1381 6109.96 $414743.81 $67.88
PHY -97110HM PT SESSION BY PT ASST 62 66 387.13 $21028.71 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 317 331 341.90 $341.90 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 9 7.36 $478.51 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 9 14.00 $3319.68 $237.12
SENS -V5264 EARMOLD 29 29 46.42 $869.03 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 8.52 $426.07 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 55 60 180.24 $9011.90 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2271 2591 12496.83 $848284.79 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 13.00 $706.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 111 115 611.07 $8066.07 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 4 20.14 $2014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1834 2546 267067.17 $133533.58 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 9.23 $461.43 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 48 52 288.59 $14429.68 $50.00
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Subtotal (Total Children Is Unduplicated) 5287 14395 315483.24 $3065653.76 $9.72
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Total 18153 320377.96 $3349717.98 $10.46
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Number of Children (Unduplicated) With at Least One Authorization 6091