Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 10-01-15 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 4940 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 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 0.928571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 55 58 180.361106 $6673.3400 $37.0000
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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
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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 53 62 398.561252 $19928.0700 $50.0000
INTR -T1013 INTERPRETER 80 116 808.924004 $40446.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1090 1806 12264.628551 $122646.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 11 62.080951 $4435.0700 $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 1128 2044 22210.863300 $9883.8400 $0.4500
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Subtotal (Total Children Is Unduplicated) 1220 4666 38022.074693 $267504.5200 $7.0400
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Total 4940 39537.901548 $316094.6300 $7.9900
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Number of Children (Unduplicated) With at Least One Authorization 1260