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
Eligibility Filter: Program Patients
With the filters selected there were 7278 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 3 2.311111 $85.5100 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.928571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 65 70 187.394439 $6933.5700 $37.0000
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Subtotal (Total Children Is Unduplicated) 68 74 190.634121 $7019.0900 $36.8200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 24 19.912438 $965.7500 $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) 3 3 91.763166 $802.9300 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 91.763166 $2004.1100 $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) 3 3 91.733333 $2341.9500 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.244444 $11.4400 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.244444 $29.2300 $119.5800
EVAL -96111 DEVELOPMENTAL EVALUATION 6 11 20.000000 $1000.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 177 201 380.631699 $19031.5800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.004110 $0.3100 $74.8200
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 3.009589 $167.0300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 22.039725 $1652.9800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 15.500000 $1162.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 4.504110 $337.8100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 46 46 45.442072 $2522.0400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 14 11.520549 $864.0400 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 33.022222 $1685.7800 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 5 6 0.761644 $114.2700 $150.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 68.000000 $3471.4000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.938889 $14.6500 $15.6000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0600 $51.0800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 41.494444 $2118.2900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.083333 $4.2500 $51.0300
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Subtotal (Total Children Is Unduplicated) 277 376 1592.280695 $56278.7900 $35.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 95.090183 $475452.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 20 22 84.539868 $4227.0100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 222 249 159.834198 $7991.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 1.133334 $28.3400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 167 373 953.993231 $47699.6900 $50.0000
CONIP -CONIP CONSULT, PHONE 7 17 27.533336 $688.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 3.071429 $76.7900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 255 315 2167.630911 $108381.7100 $50.0000
INTR -T1013 INTERPRETER 87 125 850.566860 $42528.3900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1456 2483 16504.027192 $165040.4500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 28 157.580951 $11257.6100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.857143 $220.6300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 44 342.233333 $24449.1400 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.521156 $163.8700 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.244444 $28.9800 $118.5400
SENS -V5264 EARMOLD 3 3 91.496499 $1646.9400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 94 114 1045.395232 $74683.1200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 123.357144 $1712.2000 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 167 204 1279.892574 $639.9500 $0.5000
TRAV -TRAVS Travel by mile 1513 2823 30893.564446 $13747.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 1635 6828 54787.563464 $980664.4000 $17.9000
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Total 7278 56570.478280 $1043962.2800 $18.4500
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Number of Children (Unduplicated) With at Least One Authorization 1689