Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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: 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT TRANSITION ASSESSMENT 42 42 84.00 $4200.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $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 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 3.90 $189.15 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 113 177 319.50 $20401.75 $63.86
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 5.50 $275.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 3.00 $75.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 14 12.75 $637.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 25 27.87 $1393.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 3 2.25 $56.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 2 1.52 $37.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 23 24.60 $1230.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 1.50 $37.50 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 19.29 $241.07 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 265.71 $6642.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 147 190 1420.33 $71016.64 $50.00
INTR -INTR INTERPRETER 9 10 15.29 $764.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 58 367.10 $24918.44 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 66.43 $3608.39 $54.32
PHY -97110 PT SESSION BY LICENSED PT 33 41 345.06 $23422.95 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 31.36 $1703.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 15 15.00 $15.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 53 66 495.92 $33663.27 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 10 58.87 $777.10 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 17.86 $892.86 $50.00
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Subtotal (Total Children Is Unduplicated) 254 496 3206.20 $177658.67 $55.41
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Total 673 3525.70 $198060.42 $56.18
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Number of Children (Unduplicated) With at Least One Authorization 285