Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 7.00 $339.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.18 $9.67 $54.38
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 7.00 $327.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 122 125 128.20 $15332.72 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 13 18.00 $2250.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 13.86 $769.07 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 8 8 9.67 $483.33 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 24 41.98 $2036.08 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 31 32 39.14 $1898.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 48 87.86 $4261.07 $48.50
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Subtotal (Total Children Is Unduplicated) 189 266 352.88 $27707.47 $78.52
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 12.00 $18000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 4.57 $314.79 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 11 13 34.33 $1716.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 30 32 51.11 $2555.72 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 9 60.75 $1518.75 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 21.83 $1091.66 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.73 $93.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 11 19.06 $953.10 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.75 $18.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 19 57.68 $2884.04 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 63.15 $1578.63 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 13.13 $964.25 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 95 106 277.46 $6936.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 385 497 3298.91 $164945.35 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 5.28 $263.81 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 12 71.08 $3554.04 $50.00
INTR -INTR INTERPRETER 6 6 77.14 $3857.13 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 4 6 97.71 $6632.85 $67.88
OCCT -97530HM OT SESSION BY OT ASST 36 43 442.12 $24016.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 64.29 $4363.71 $67.88
PHY -97110HM PT SESSION BY PT ASST 53 67 633.81 $34428.65 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 40 47 37.49 $37.49 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 7 6.70 $435.62 $65.00
SENS -V5264 EARMOLD 9 11 11.30 $211.54 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 8 20.15 $1007.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 10.00 $678.80 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 48 61 866.62 $11439.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.14 $57.15 $50.00
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Subtotal (Total Children Is Unduplicated) 457 1009 6268.31 $296580.15 $47.31
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Total 1275 6621.19 $324287.62 $48.98
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Number of Children (Unduplicated) With at Least One Authorization 466