Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 07-01-11 and 09-30-11 Date of Report: 11-30-11 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.428571 $89.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.678571 $99.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.800000 $70.3400 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 32 32 33.733333 $2024.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.733333 $213.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 23 23 23.600000 $2714.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.000000 $500.0000 $125.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 3.000000 $225.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 27.285714 $1514.3600 $55.5000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.000000 $150.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 12.000000 $582.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 17 17.000000 $824.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 47 48 48.000000 $2328.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 122 174 186.152380 $11611.2000 $62.3700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 10 35.571429 $53357.1000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 7 8 23.661905 $1183.1000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 28 39.176191 $1958.8200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 3.000000 $75.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.800000 $290.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 38 49.161905 $2458.1000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 35 41.838812 $2091.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.833333 $170.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 38.239683 $2803.7300 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.285714 $107.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 21 55.857142 $1396.4300 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.285714 $407.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 267 1214.680939 $60734.1300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 20.176190 $1008.8100 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 18 94.142856 $6390.4200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 10 67.714286 $3678.2400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 25 26 179.695236 $12197.7200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 9 45.357142 $2463.8000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 7.804763 $7.8000 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.117808 $267.6600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 7 8 9.611112 $173.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 8 11.619047 $580.9500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 29 164.785713 $11185.6600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.428571 $240.5600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 9 10 57.566667 $759.8800 $13.2000
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Subtotal (Total Children Is Unduplicated) 273 581 2211.412158 $167118.8200 $75.5700
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Total 758 2400.243109 $178829.1300 $74.5000
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Number of Children (Unduplicated) With at Least One Authorization 281