Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 5.00 $300.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.29 $535.71 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 4 6 7.00 $350.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 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 11 11 18.50 $1387.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 12.00 $666.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 35 50 82.50 $6187.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 64 67 83.74 $4061.44 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 16 15.04 $729.65 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 53 58 54.04 $2620.84 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 145 158 135.81 $6586.87 $48.50
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Subtotal (Total Children Is Unduplicated) 256 392 433.42 $24219.62 $55.88
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 5.50 $275.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.50 $37.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 37 34.93 $1746.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 9 13.73 $343.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 25 20.83 $1041.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 9.00 $225.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 25 17.60 $880.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 9 20.52 $513.04 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 41 48.54 $2427.14 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 29.12 $728.04 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 68.43 $855.36 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 479 598 4563.79 $228189.45 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 38.40 $1919.77 $50.00
INTR -INTR INTERPRETER 3 3 15.00 $750.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 84 94 731.40 $49647.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 21 25 221.14 $12012.47 $54.32
PHY -97110 PT SESSION BY LICENSED PT 101 123 1024.39 $69535.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 24 30 249.57 $13556.71 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 57 64 64.17 $64.17 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -V5264 EARMOLD 2 3 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 236 276 2477.67 $168184.41 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.29 $395.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 61 73 533.43 $7041.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 14 17 2734.00 $1367.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 65.49 $3274.29 $50.00
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Subtotal (Total Children Is Unduplicated) 774 1497 13006.45 $571555.41 $43.94
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Total 1890 13440.87 $595812.03 $44.33
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Number of Children (Unduplicated) With at Least One Authorization 779