Summary Report for FSPSAs Ending During the Report Period Center: 04
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 1401 FSPSA's found of which 1 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.100002 $3.7000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 0.100002 $3.7000 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.449392 $21.8000 $48.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 2.511111 $128.1900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 25 9.984127 $509.6900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 23 23 4.466669 $228.0400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.253175 $829.7300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 27 27 44.962697 $2295.3500 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 84 106 78.627171 $4012.7900 $51.0400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 17 2.088887 $104.4400 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 1 1 0.677778 $33.8900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 56 68 394.428575 $9860.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 475 507 2968.131309 $148406.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 439 505 2857.918870 $28579.2000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 61 67 266.836505 $19062.8300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 18.642857 $1066.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 52 53 239.907145 $17138.9700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 36.571429 $2090.4200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 60 220.928575 $15783.1200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.714286 $384.0600 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 12.142858 $168.5400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 1 8.285714 $4.1400 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 581 1294 7033.274788 $242683.3100 $34.5100
-------------------------------------------------------------------------------------------------------------------------------------
Total 1401 7112.001961 $246699.7900 $34.6900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 584