Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.844444 $97.1100 $114.9900
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 7 11.000000 $1375.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 49 56 115.000000 $5750.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 7.000000 $525.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 76 76 152.000000 $11400.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 46 46 92.000000 $6900.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 49 49 98.000000 $5439.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 72 73 146.000000 $10950.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 20 22.066667 $1070.2400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.000000 $339.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 23 24.000000 $1164.0000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 209 383 713.911111 $47815.3400 $66.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 21 28.000000 $42000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.533333 $126.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 345 920 2754.480895 $137723.7800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 341 483 4051.409506 $202570.5000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 6.857143 $171.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 110 143 1201.214280 $60060.7300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 15.428571 $385.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 172 242 1956.776179 $97838.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 51.714285 $1292.8600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 260 337 2899.928561 $144996.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.000000 $50.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 56 378.600003 $9465.0100 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.800000 $20.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 335 457 3309.053978 $165452.8000 $50.0000
INTR -INTR INTERPRETER 16 22 163.285714 $8164.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 42 187.392858 $12720.2300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 8 42.978573 $2334.5900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 89 115 523.773817 $35553.7900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 3 15.500000 $841.9600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 51 56 150.714286 $150.7100 $1.0000
SENS -V5264 EARMOLD 1 1 0.844444 $15.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 144 178 940.014294 $63808.1500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 7.800001 $102.9600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 375 915 765441.790514 $382720.9000 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 421 4011 784132.891235 $1368567.5200 $1.7500
-------------------------------------------------------------------------------------------------------------------------------------
Total 4394 784846.802346 $1416382.8600 $1.8000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 451