Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 7.383334 $273.1900 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 7.383334 $273.1900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 71 72 70.571428 $836.9800 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 69 70 68.571428 $567.7700 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 69 70 68.571428 $711.7700 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 69 70 68.571428 $1445.4900 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 50 51 50.285714 $1367.2700 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 88 97 95.466666 $5728.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.133333 $141.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 9.000000 $1035.0000 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 29 40 36.877776 $1843.8800 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 38 40.000001 $1940.0100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.000000 $533.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 38 49 49.448402 $2398.2500 $48.5000
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Subtotal (Total Children Is Unduplicated) 239 579 571.497604 $18548.9000 $32.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 26 135.000000 $202500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 9 25.095238 $1254.7600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 66 78 77.714286 $3885.7200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 100 40.038885 $2001.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 108 58.599995 $2929.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 43 41.338885 $2066.9300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 183 220 149.516656 $7475.7800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 21 150.933335 $3773.3400 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.333333 $166.6700 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 33.400001 $835.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 399 566 4390.541669 $219527.1000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 22 27 191.299999 $9565.0000 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 245 334 1757.827782 $119321.3800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 16 16 95.466665 $5185.7400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 468 662 2816.667991 $191195.3700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 12 75.450001 $4098.4500 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 160 192 192.000000 $192.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.000000 $1500.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 8 9 16.000000 $288.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 19 41.183333 $2059.1700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 402 566 2974.768251 $201927.2400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 19.133333 $1039.3200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 39.866668 $526.2400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4 4 630.666666 $315.3300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 11.300000 $565.0000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 29 43 163.280555 $8164.0300 $50.0000
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Subtotal (Total Children Is Unduplicated) 1107 3085 14160.323527 $994403.9400 $70.2200
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Total 3672 14739.204465 $1013226.0300 $68.7400
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Number of Children (Unduplicated) With at Least One Authorization 1123