Summary Report for FSPSAs Initiated During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting between: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 0.25 $9.25 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 10.29 $380.57 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 10.54 $389.82 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 8.00 $388.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 22 26.14 $1568.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 9.00 $1076.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.25 $62.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 66 71 139.00 $6950.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 41 74.50 $5587.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 14.00 $1050.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 15.00 $1125.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 39 39 73.00 $5475.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 42.00 $2331.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 365 413 775.71 $58178.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 63 120.50 $9037.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 87 96 176.50 $13237.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 338 389 730.21 $40526.63 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 215 240 441.00 $33075.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 9.00 $436.50 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 12.43 $602.79 $48.50
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Subtotal (Total Children Is Unduplicated) 613 1453 2678.24 $181203.01 $67.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 12 16.00 $24000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 14.07 $703.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 62 69 103.89 $5194.65 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 9.18 $229.47 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 17 24.56 $1228.10 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 14 14 24.55 $613.87 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 7 6.83 $341.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 5 7.84 $195.95 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 6.60 $330.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 10 11.15 $278.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 15 15.47 $773.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 13 19.84 $495.95 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 25 95.71 $2392.85 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 18.86 $471.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 376 391 2119.55 $105977.69 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 7.71 $385.71 $50.00
INTR -INTR INTERPRETER 69 97 241.81 $12090.49 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 22 23 155.29 $10540.79 $67.88
PHY -97110 PT SESSION BY LICENSED PT 69 74 484.07 $32858.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 4 30.00 $1629.60 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 46 47 45.14 $45.14 $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 2 2 2.00 $130.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 5 10.00 $187.20 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.29 $64.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 131 140 1061.17 $72032.00 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 85.57 $1129.54 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 5.14 $514.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 528 719 3694.55 $1847.27 $0.50
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Subtotal (Total Children Is Unduplicated) 622 1727 8322.85 $278007.38 $33.40
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Total 3184 11011.62 $459600.22 $41.74
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Number of Children (Unduplicated) With at Least One Authorization 870