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: 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 1 1 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.000000 $37.0000 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 57 63 71.304761 $4278.2800 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 17 18.500000 $832.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 50 53 57.733334 $6639.3400 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 17 17 28.595237 $3574.4000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 11 11 18.000000 $900.0000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 31 54.142857 $3004.9300 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 5 5 5.000000 $250.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 14 14.000000 $679.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.000000 $776.0000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 54 56 56.000000 $2716.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 202 299 355.276189 $24538.4500 $69.0700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 20 30.000000 $45000.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $137.7200 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 16 22 94.574605 $4728.7300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 47 58 111.738094 $5586.8900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 14 18 18.151190 $453.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 21 26.566667 $1328.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 76 87 106.814286 $5340.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 10.000000 $250.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 70 90.718723 $4535.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 13 20.166666 $504.1700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 16 57.446031 $4211.9400 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 10.428572 $260.7100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 43 161.804767 $4045.1300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 39.428571 $1971.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 13.142857 $328.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 413 581 3669.798405 $183490.0200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 14 54.061906 $2703.1000 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 31 252.928573 $17168.8000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 10 11 113.000002 $6138.1500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 50 58 546.923810 $37125.2000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 13 13 79.638096 $4325.9400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 26 22.782538 $22.7800 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 4.252055 $276.3800 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 3 6.000000 $1368.0000 $228.0000
SENS -V5264 EARMOLD 13 17 26.544443 $477.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 23 27 37.631744 $1881.5800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 48 58 426.609521 $28958.3000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 17 20 144.104762 $1902.1800 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.857143 $642.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 475 1260 6196.114027 $365440.1400 $58.9800
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Total 1560 6552.390216 $390015.5900 $59.5200
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Number of Children (Unduplicated) With at Least One Authorization 478