Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 3.00 $0.00 $0.00
TCON -TCON TRANSITION CONFERENCE 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 4 5 5.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 26 26 51.00 $2550.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.50 $487.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 60 60 104.50 $7837.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 36 65.50 $4912.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 16.00 $1200.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 64 64 112.07 $6219.70 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 18 34.00 $2550.00 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 6.57 $318.71 $48.50
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Subtotal (Total Children Is Unduplicated) 131 237 413.64 $27114.16 $65.55
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 13.75 $687.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.77 $19.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 10 10 8.50 $425.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 17.17 $858.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 9.50 $475.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.00 $25.00 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 235.71 $2946.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 108.57 $2714.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 90 95 519.54 $25976.92 $50.00
INTR -INTR INTERPRETER 12 19 27.00 $1350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 26 27 194.86 $13226.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.86 $807.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 14 14 92.14 $6254.66 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 11.29 $613.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 37 252.04 $17108.34 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.00 $26.40 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 7.29 $364.29 $50.00
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Subtotal (Total Children Is Unduplicated) 155 259 1523.97 $76932.29 $50.48
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Total 501 1942.61 $104046.45 $53.56
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Number of Children (Unduplicated) With at Least One Authorization 200