Summary Report for FSPSAs Initiated During the Report Period Statewide
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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 6 6 12.54 $463.82 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 58 70 73.00 $3540.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 59 59 53.20 $564.98 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 56 56 51.17 $451.80 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 56 56 51.17 $552.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 57 57 51.20 $1115.64 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 46.20 $1306.53 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 167 170 162.60 $9755.89 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 21 21 23.20 $1085.76 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 98 98 103.68 $12399.85 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 3.36 $419.64 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 15.29 $1910.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 20 20 24.99 $1249.65 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 175 185 343.14 $17157.15 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 49 50 89.50 $6712.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 19.00 $1425.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 11 19.50 $1462.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 43 43 78.00 $5850.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 33 34 59.50 $3302.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 10 10 20.00 $1110.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 467 515 969.78 $72733.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 134 140 262.36 $19676.78 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 132 141 266.00 $19950.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 435 486 911.74 $50601.73 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 288 328 598.00 $44850.00 $75.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 7 7 7.13 $356.67 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 50 59 59.00 $2861.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 416 460 511.21 $24793.86 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 62 71 76.86 $3727.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 294 313 320.06 $15522.96 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 24 24 24.00 $1200.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 766 823 893.67 $43343.08 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2455 4390 6195.53 $371238.18 $59.92
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 52 56 115.00 $172500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 9.57 $659.09 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 12.00 $826.32 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 58 59 101.99 $5099.62 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 367 456 678.45 $33922.70 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 13 13 14.93 $373.22 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 586 623 914.52 $45726.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 52 52 66.77 $1669.14 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 312 340 440.28 $22014.20 $50.00
CONOP -CONOP CONSULT, OT, PHONE 16 18 27.89 $697.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 238 248 388.42 $19421.04 $50.00
CONPP -CONPP CONSULT, PT, PHONE 21 21 19.60 $490.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 743 782 991.51 $49575.65 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 65 66 70.62 $1765.56 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 16.13 $1184.51 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 37.00 $462.50 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 17.00 $425.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 204 229 1424.37 $35609.18 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.86 $142.86 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.14 $7.22 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 15 17 83.93 $4196.67 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 37.69 $942.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2613 2855 16174.14 $808706.85 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 8 8 17.01 $850.42 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 36 36 104.67 $5233.34 $50.00
INTR -INTR INTERPRETER 145 179 665.88 $33294.08 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 998 1154 5838.37 $396308.38 $67.88
OCCT -97530HM OT SESSION BY OT ASST 53 54 325.62 $17687.89 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1230 1433 6622.33 $449523.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 64 66 382.53 $20778.96 $54.32
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 302 309 293.99 $293.99 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 8.00 $4000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.43 $288.16 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 9 12.00 $2845.44 $237.12
SENS -V5264 EARMOLD 40 43 55.50 $1038.96 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 9.10 $455.01 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 59 66 153.22 $7661.22 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2145 2519 12282.15 $833712.17 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 25.32 $1375.59 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 103 109 841.30 $11105.10 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 4 16.00 $1600.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1928 2634 307302.85 $153651.42 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 3.27 $163.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 42 45 179.12 $8956.11 $50.00
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Subtotal (Total Children Is Unduplicated) 5376 14543 356789.49 $3157354.26 $8.85
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Total 18939 362997.56 $3529056.26 $9.72
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Number of Children (Unduplicated) With at Least One Authorization 5868