Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 1998 FSPSA's found of which 29 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 27 36 7.471863 $362.3900 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 6 6 3.975039 $198.7500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 41 42 56.407042 $2820.3700 $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 0.158904 $8.1100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.120548 $6.1500 $51.0300
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 32 33 11.580952 $1737.1800 $150.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.046575 $2.3800 $51.0800
SCREEN-T1023 SCREENING 3 3 0.509666 $25.4900 $50.0100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.142466 $7.2700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 3.406262 $173.8900 $51.0500
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Subtotal (Total Children Is Unduplicated) 100 140 83.890545 $5346.6400 $63.7300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 39 43 15.347917 $767.3600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 6.285714 $157.1400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 130 332 548.053664 $27402.7900 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 6.133334 $153.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 229.142856 $5728.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 40 42 300.080951 $15004.0700 $50.0000
INTR -T1013 INTERPRETER 12 17 37.143150 $1857.1600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 287 505 4249.126773 $42491.2700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 32.785715 $2342.2100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 7 50.285713 $3592.4200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 21 169.785712 $12129.5000 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 186 279 1495.721943 $747.8600 $0.5000
TRAV -TRAVS Travel by mile 275 597 108375.027506 $48226.8900 $0.4500
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Subtotal (Total Children Is Unduplicated) 407 1858 115514.920948 $160600.5800 $1.3900
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Total 1998 115598.811493 $165947.2200 $1.4400
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Number of Children (Unduplicated) With at Least One Authorization 414