Summary Report for FSPSAs Initiated During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 4855 FSPSA's found of which 12 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 55 58 180.361106 $6673.3400 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 56 59 181.289677 $6673.3400 $36.8100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 18 17.357491 $841.8300 $48.5000
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) 1 1 91.000000 $796.2500 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 91.000000 $1987.4400 $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) 2 2 91.488889 $2335.7100 $25.5300
EVAL -96111 DEVELOPMENTAL EVALUATION 5 9 16.000000 $800.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 141 159 298.626220 $14931.3100 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 5.519177 $306.3200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 3.500000 $262.5000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 3 0.389041 $58.3700 $150.0200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 68.000000 $3471.4000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0600 $51.0800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 173 215 1334.537178 $41916.7600 $31.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.379833 $1899.5000 $5000.8800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 11 55.333377 $2766.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 164 180 123.291875 $6164.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 1.133334 $28.3400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 112 229 616.339605 $30816.9600 $50.0000
CONIP -CONIP CONSULT, PHONE 3 5 8.433335 $210.8400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.214286 $55.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 52 61 394.132681 $19706.6400 $50.0000
INTR -T1013 INTERPRETER 79 115 802.924004 $40146.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1067 1763 11919.657124 $119196.6900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 10 60.080951 $4292.1900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 11 16 123.357144 $8812.6300 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.521156 $163.8700 $65.0000
SENS -V5264 EARMOLD 1 1 91.000000 $1638.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 26 228.333333 $16312.1500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 58.571429 $812.9700 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 122 148 966.107928 $483.0500 $0.5000
TRAV -TRAVS Travel by mile 1108 2005 21642.329968 $9630.8400 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1200 4581 37096.141363 $263137.5000 $7.0900
-------------------------------------------------------------------------------------------------------------------------------------
Total 4855 38611.968218 $311727.6000 $8.0700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1240