Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.428571 $385.8600 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 10 10 21.526191 $796.4700 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 32.954762 $1182.3300 $35.8800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 71 74 92.142857 $4468.9300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.044444 $79.9000 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 71 72 70.571428 $836.9800 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 9 9.000000 $137.2500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 76 79 77.571428 $642.2900 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 77 81 78.593650 $815.8000 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 77 81 78.593650 $1656.7500 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 12 12 12.000000 $621.1200 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 53 54 53.285714 $1448.8400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 288 309 327.212695 $19632.7400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 41 44 46.633333 $2098.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 92 95 105.644445 $12149.1200 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 11 11 43.928572 $5491.0800 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 45 48 90.309523 $11288.6900 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 43 55 58.092062 $2904.6000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 317 329 613.783333 $30689.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 22 22 42.000000 $3150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 27 28 50.000000 $3750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 59 65 110.651077 $6141.1400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 265 265 516.500000 $38737.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 109 109 204.000000 $15300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 50 50 98.500000 $7387.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 263 263 508.500000 $28221.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 322 349 692.533333 $51940.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
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 6 6 6.000000 $300.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 52 57 64.285715 $3117.8600 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 506 594 637.595239 $30923.3800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 43 48 48.000000 $2328.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 498 567 604.123810 $29300.0100 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 28 28.000000 $1400.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.000000 $30.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 771 855 952.985704 $46219.8200 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 5 6 13.000000 $650.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2863 4681 6357.582012 $365321.1900 $57.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 108 122 277.857143 $416785.8000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 4.533333 $312.1600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 111 142 299.092065 $14954.6000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 759 1395 3302.026493 $165101.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 29 31 36.299208 $907.4800 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1798 2303 6938.506751 $346925.4500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 97 115 192.615481 $4815.4000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 694 845 2271.879767 $113594.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 31 34 67.506352 $1687.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 799 1011 3194.299607 $159715.0800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 65 68 170.849209 $4271.2400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2329 2811 6213.737389 $310686.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 113 127 198.789684 $4969.7500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 16 57.446031 $4211.9400 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 1243.857143 $15548.2100 $12.5000
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 350 413 4162.623807 $104065.7300 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 14 166.357143 $8317.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 7 25.142856 $1257.1400 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 20 20 157.266667 $3931.6800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6440 8335 64606.788060 $3230342.0400 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 19.714286 $985.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 77 91 557.274606 $27863.7500 $50.0000
INTR -INTR INTERPRETER 246 390 2394.878175 $119743.9400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1527 1967 13218.396860 $897265.1800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 70 73 511.064285 $27761.0200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 2175 2857 17924.539874 $1216718.1100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 70 76 567.016667 $30800.3800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 722 818 942.131743 $942.1300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 17 17 25.000000 $12500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 11 13 13.207611 $858.4900 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 10 18.000000 $4104.0000 $228.0000
SENS -V5264 EARMOLD 70 82 109.888883 $1977.9900 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 10.285714 $514.2900 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 130 152 457.303968 $22865.2100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2932 3726 25062.317875 $1701231.1200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 58.276190 $3165.5600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 79 87 640.278571 $8451.6800 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.285714 $128.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4641 7618 1789678.367499 $894839.1600 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 9 11 50.911905 $2545.5900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 85 107 526.523416 $26326.1700 $50.0000
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Subtotal (Total Children Is Unduplicated) 10203 35929 1946389.966603 $9914584.0000 $5.0900
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Total 40622 1952780.503377 $10281087.5200 $5.2600
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Number of Children (Unduplicated) With at Least One Authorization 10398