Summary Report for FSPSAs Ending During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3740 FSPSA's found of which 8 had no frequency modifier field, FORCE FREQ MODIFIER to 0
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.928571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 33 33 152.578571 $5645.4100 $37.0000
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Subtotal (Total Children Is Unduplicated) 33 34 153.507142 $5645.4100 $36.7800
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $205.2600 $102.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 4.915297 $238.3900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.116667 $5.5000 $47.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 91.000000 $1358.6300 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 91.000000 $1747.2000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 91.000000 $948.2200 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 91.000000 $1997.4500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 92.000000 $805.0000 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 92.000000 $2009.2800 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 91.000000 $2629.9000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 91.000000 $5927.7400 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 91.000000 $2323.2300 $25.5300
EVAL -96111 DEVELOPMENTAL EVALUATION 5 8 13.000000 $650.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 140 158 298.576905 $14928.8400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 9.513698 $713.5300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 7.300782 $547.5600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 4.508220 $338.1200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 16 14.311740 $1073.3900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 12 18.000000 $999.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 124 124 134.439851 $10083.0200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 59 59 72.240316 $5418.0200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 33 34 30.065754 $2254.9300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 156 157 186.149313 $10331.2900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 81 96 114.579450 $8593.4600 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 3.000000 $153.1500 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 3 0.389041 $58.3700 $150.0200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 68.554033 $3499.6800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.561188 $79.7000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 62.000000 $3165.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 421 721 1957.222255 $83816.3900 $42.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.448228 $37241.5000 $5000.0500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 5.263014 $263.1500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 162 176 115.822285 $5791.0800 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 54 89 137.342776 $6867.1100 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 0.933334 $23.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 14.642857 $366.0700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 506 548 2954.849714 $147742.4100 $50.0000
INTR -T1013 INTERPRETER 52 72 354.695434 $17734.7700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 546 773 3283.675364 $32836.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 63.104761 $4508.2100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 56 65 325.703180 $23268.2000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.000000 $285.8000 $57.1600
SENS -V5264 EARMOLD 2 2 91.263014 $1642.7300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 82 521.761905 $37274.6600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 103.071430 $1430.6300 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 91 114 542.552373 $271.2800 $0.5000
TRAV -TRAVS Travel by mile 692 1026 5932.990709 $2640.1800 $0.4400
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Subtotal (Total Children Is Unduplicated) 785 2985 14460.120378 $320187.8300 $22.1400
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Total 3740 16570.849775 $409649.6300 $24.7200
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Number of Children (Unduplicated) With at Least One Authorization 940