Summary Report for FSPSAs Ending During the Report Period Center: 02
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 821 FSPSA's found of which 22 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 2.783483 $135.0000 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.002740 $0.1400 $49.2700
EXIT -EXIT EXIT ASSESSMENT 11 11 6.077406 $303.8800 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 0.021916 $1.6500 $75.2900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 0.035614 $1.9800 $55.6200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 0.008219 $0.6200 $74.8300
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.093151 $4.7600 $51.0800
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 23 24 9.805610 $1470.8900 $150.0000
SCREEN-T1023 SCREENING 1 1 0.005556 $0.2800 $50.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 3.285714 $167.7400 $51.0500
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Subtotal (Total Children Is Unduplicated) 49 64 22.124888 $2087.3200 $94.3400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 26 1.151451 $57.5400 $49.9700
CONIF -CONIF CONSULT, FACE TO FACE 48 82 133.148702 $6657.4600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 13.000000 $325.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 16 17 87.871429 $4393.5700 $50.0000
INTR -T1013 INTERPRETER 11 14 8.714579 $435.7300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 113 156 1554.459901 $15544.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 15.285715 $1092.0100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 11.285714 $806.2500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 25.571429 $1826.8100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 113 175 605.627090 $302.8100 $0.5000
TRAV -TRAVS Travel by mile 160 273 27176.423153 $12093.5100 $0.4500
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Subtotal (Total Children Is Unduplicated) 272 757 29632.539163 $43535.2600 $1.4700
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Total 821 29654.664051 $45622.5900 $1.5400
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Number of Children (Unduplicated) With at Least One Authorization 278