Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.00 $333.00 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 9.00 $333.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 10 10.00 $485.00 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 5.71 $61.71 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 5.71 $310.74 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 5.71 $181.77 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 35 36 37.00 $2220.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.51 $117.26 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 18 21.00 $2511.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 112 119 229.25 $11462.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 39 40 80.00 $6000.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 30 60.00 $4500.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 44.00 $2442.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 307 319 638.50 $47887.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 35 70.00 $5250.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 66 68 135.00 $10125.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 251 255 510.00 $28305.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 144 145 289.50 $21712.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 8 12.57 $609.71 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 15.00 $727.50 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 16 16.00 $776.00 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 614 1152 2207.47 $147146.30 $66.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 23 23.00 $34500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 41.40 $2070.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 95 105 161.77 $8088.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 22 25 25.30 $632.62 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 41 70.98 $3548.80 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 26 31 67.52 $1687.91 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 6 13.73 $686.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 12.13 $303.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 22 36.20 $1809.99 $50.00
CONPP -CONPP CONSULT, PT, PHONE 15 16 35.45 $886.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 36 74.82 $3741.18 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 31 63.88 $1597.02 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 54 428.57 $10714.29 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 41.00 $1025.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 875 1094 8503.41 $425170.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 44.00 $2200.00 $50.00
INTR -INTR INTERPRETER 136 191 791.11 $39555.73 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 50 65 527.18 $35784.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.00 $434.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 188 230 1985.16 $134752.94 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 8 95.86 $5206.96 $54.32
RSPT -RSPT RESPITE 1 2 48.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 105 113 126.67 $126.67 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.00 $260.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 8 8 15.37 $287.73 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 47.75 $2387.38 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 304 391 3307.95 $224543.57 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 22 182.83 $2413.30 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 17.86 $1785.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1129 1854 14001.52 $7000.76 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 28.14 $1407.15 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1271 4415 30840.10 $957408.88 $31.04
-----------------------------------------------------------------------------------------------------------------------------
Total 5570 33056.57 $1104888.18 $33.42
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1435