Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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
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 39 39 77.00 $3850.00 $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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 7.57 $367.21 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 151 258 447.64 $28805.16 $64.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 13.75 $687.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 2 3.03 $75.84 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 16 14.50 $725.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 38 40.43 $2021.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.00 $50.00 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.52 $37.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 22 21.97 $1098.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.52 $62.92 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 235.71 $2946.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 7 319.29 $7982.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 204 1451.33 $72566.67 $50.00
INTR -INTR INTERPRETER 14 24 32.00 $1600.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 58 69 471.27 $31989.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 9 34.39 $1868.09 $54.32
PHY -97110 PT SESSION BY LICENSED PT 38 41 347.99 $23621.58 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 17.93 $973.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 12 24.00 $24.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 63 79 616.32 $41835.90 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 9 57.30 $756.42 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 4 20.50 $1025.00 $50.00
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Subtotal (Total Children Is Unduplicated) 283 567 3736.75 $198173.87 $53.03
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Total 830 4189.39 $226979.04 $54.18
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Number of Children (Unduplicated) With at Least One Authorization 316