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 2 2 0.638889 $23.6400 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 12.067460 $409.5000 $33.9300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 62 65 83.142857 $4032.4300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 10.285714 $121.9900 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 9.285714 $76.8900 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 10.285714 $106.7700 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 10.285714 $216.8200 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 6.000000 $163.1400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 20 21 21.022222 $1261.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.000000 $805.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 6.571429 $821.4300 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 12.000000 $1500.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 12 12 13.000000 $650.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 311 322 599.783333 $29989.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 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 20 20 40.000000 $3000.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 39 39 76.500000 $4245.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 35 70.000000 $5250.0000 $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 13 14 15.000000 $727.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 41 41 40.966667 $1986.8900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 5.000000 $242.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 33 34 34.000000 $1649.0000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 70 72 74.966667 $3635.8900 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 5 6 13.000000 $650.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 634 781 1202.096031 $64041.2300 $53.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 28 55.000000 $82500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 69 84 195.831747 $9791.5800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 756 1391 3296.526493 $164826.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 29 31 36.299208 $907.4800 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1792 2296 6923.306750 $346165.4500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 97 115 192.615481 $4815.4000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 682 831 2242.925798 $112146.3100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 31 34 67.506352 $1687.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 790 1001 3171.425004 $158571.3600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 64 67 169.815876 $4245.4100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2309 2791 6159.689770 $307984.5700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 112 126 196.256351 $4906.4100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.022222 $74.9500 $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 26 33 221.895241 $5547.3900 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 102.857143 $5142.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 16.999999 $850.0000 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 10.933334 $273.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 400 461 3736.561915 $186828.2100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 13.142857 $657.1500 $50.0000
INTR -INTR INTERPRETER 245 389 2383.449604 $119172.5100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 132 157 1019.444449 $69199.9300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 24.542857 $1333.1700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 202 261 1180.683739 $80144.8500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 10 10 81.423810 $4422.9500 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 717 811 935.531743 $935.5300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 14.000000 $7000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 8 7.252055 $471.3800 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 4 4 6.000000 $108.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 20.409524 $1020.4800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 359 431 2863.092062 $194346.7800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 18.709525 $246.9700 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.285714 $128.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4620 7574 1783962.572260 $891981.2700 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.571429 $78.5700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 3.357143 $167.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 7327 18978 1819352.766027 $2770073.0900 $1.5200
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Total 19763 1820566.929518 $2834523.8200 $1.5600
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Number of Children (Unduplicated) With at Least One Authorization 7445