Summary Report for FSPSAs Initiated During the Report Period Center: 02
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
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT TRANSITION ASSESSMENT 24 24 48.00 $2400.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.00 $150.00 $75.00
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 38 38 70.57 $5292.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 42.50 $3187.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 55.53 $3082.10 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 38.00 $2850.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 89 151 274.60 $18114.10 $65.97
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 5.50 $275.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 10 8.75 $437.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 11.60 $580.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.25 $31.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.25 $31.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 12 12.00 $600.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.23 $30.83 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 74 78 460.13 $23006.72 $50.00
INTR -INTR INTERPRETER 2 2 6.29 $314.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 21 21 83.62 $5676.40 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.93 $322.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 10 10 75.60 $5131.73 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.93 $322.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 25 118.31 $8030.86 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 21.90 $289.08 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.71 $185.72 $50.00
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Subtotal (Total Children Is Unduplicated) 126 197 832.01 $49868.71 $59.94
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Total 348 1106.61 $67982.81 $61.43
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Number of Children (Unduplicated) With at Least One Authorization 158