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: 07/01/10 and 09/30/10 Date of Report: 11-17-10 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 3.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 3.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $21.6000 $10.8000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.022222 $61.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 123 130 146.687301 $16869.0400 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 16 19 23.000000 $2875.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 25 25 30.000000 $1665.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 11 11 16.833333 $841.6700 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 26.833333 $1301.4200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 48 52.180953 $2530.7800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 65 71 132.714286 $6436.6400 $48.5000
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Subtotal (Total Children Is Unduplicated) 203 333 437.271428 $32884.4700 $75.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 12 13.144445 $19716.7500 $1500.0100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.700000 $193.3500 $71.6100
AUD -HA_FUP AUDIOLOGY SERVICES 15 15 52.457144 $2622.8600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 7.000000 $350.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 16 20.400001 $1020.0100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 7.092858 $177.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 12.966668 $648.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.491667 $12.2900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 13.333334 $666.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.050000 $51.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 23 54.066669 $2703.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 10.026191 $250.6600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 15 16 58.166668 $4270.6100 $73.4200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 82 88 248.290479 $6207.2800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.233333 $61.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 384 470 3087.298409 $154365.1300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 15 111.974602 $5598.7400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 41.857143 $2841.2600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 39 45 418.359524 $22725.3000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 6 6 55.638095 $3776.7100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 52 59 495.242855 $26901.6000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 40 30.977777 $30.9800 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.000000 $2000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 5.671233 $368.6300 $65.0000
SENS -V5264 EARMOLD 10 10 16.266665 $292.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 13 52.946032 $2647.3100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 87.428572 $5934.6500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 62 73 725.842852 $9581.1300 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.022222 $102.2200 $100.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 13.142857 $657.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 475 964 5651.088295 $276775.9800 $48.9800
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Total 1298 6091.359723 $309660.4500 $50.8400
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Number of Children (Unduplicated) With at Least One Authorization 493