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: 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 1 1 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 5.00 $242.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.27 $16.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 147 149 163.27 $19526.70 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 15 18 23.00 $2875.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 13.14 $729.43 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 10.70 $535.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 35.03 $1699.12 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 42 43 55.00 $2667.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 71 85.71 $4157.14 $48.50
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Subtotal (Total Children Is Unduplicated) 225 332 396.12 $32688.79 $82.52
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.93 $7399.95 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 10 12 35.90 $1795.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 6.00 $300.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 21 30.30 $1515.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 42.72 $1067.91 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 23.10 $1155.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 19.73 $986.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.18 $4.38 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 21 62.56 $3127.87 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 68.97 $1724.31 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 12 22.03 $1617.68 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 92 95 248.74 $6218.56 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 6.86 $342.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 410 501 3538.17 $176908.55 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 13 14 87.17 $4358.33 $50.00
INTR -INTR INTERPRETER 6 6 70.29 $3514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 3 4 104.00 $7059.52 $67.88
OCCT -97530HM OT SESSION BY OT ASST 39 45 380.47 $20667.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 4 4 62.00 $4208.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 52 60 631.28 $34290.94 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 39 41 33.33 $33.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 8 11.53 $749.57 $65.00
SENS -V5264 EARMOLD 8 10 13.77 $257.71 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 37.92 $1895.95 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 24.00 $1629.12 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 58 65 902.31 $11910.49 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 13.00 $650.00 $50.00
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Subtotal (Total Children Is Unduplicated) 500 984 6487.25 $297957.59 $45.93
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Total 1317 6886.38 $330646.38 $48.01
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Number of Children (Unduplicated) With at Least One Authorization 515