Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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 3151 FSPSA's found of which 58 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 39 8.093781 $392.5500 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 9 4.696806 $103.1000 $21.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 1.933334 $90.4800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 8.017743 $958.9300 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 7 7 4.144902 $207.2500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 44 56.886494 $2844.3500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.862622 $214.7000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.016437 $0.9200 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 63 63 0.330116 $24.8300 $75.2200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 0.041095 $3.0800 $75.0100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 71 71 2.139118 $118.7700 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 22 0.115060 $8.6600 $75.2200
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 8 1.764535 $90.0800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 17 21.435823 $1094.3000 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 35 36 12.287801 $1843.2200 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 1.528387 $78.0300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 6.461362 $329.8600 $51.0500
SCREEN-T1023 SCREENING 7 7 3.842999 $192.1600 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.142466 $7.2700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 21 19.401880 $990.4700 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.504110 $25.2100 $50.0100
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Subtotal (Total Children Is Unduplicated) 222 389 156.652350 $9618.6000 $61.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 34 44 9.749869 $48749.5000 $5000.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 44 15.852027 $792.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 6.285714 $157.1400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 137 348 593.164780 $29658.3700 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 6.133334 $153.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 26 919.571428 $22989.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 321 432 3185.545590 $159277.4600 $50.0000
INTR -T1013 INTERPRETER 12 17 37.143150 $1857.1600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 301 527 4443.037885 $44430.3900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 88 108 1044.671422 $74631.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.571429 $1291.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 118 152 1395.447611 $99690.8800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 49.571428 $2833.5100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.208219 $49.3700 $237.1000
SENS -V5264 EARMOLD 2 3 1.084931 $19.5300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 150 1352.589911 $96629.1400 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 190 284 1515.283197 $757.6400 $0.5000
TRAV -TRAVS Travel by mile 287 617 116454.684652 $51822.3400 $0.4500
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Subtotal (Total Children Is Unduplicated) 465 2762 131052.596577 $635790.1000 $4.8500
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Total 3151 131209.248927 $645408.7000 $4.9200
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Number of Children (Unduplicated) With at Least One Authorization 467