Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 1373 FSPSA's found
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 0.219052 $8.1100 $37.0100
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Subtotal (Total Children Is Unduplicated) 1 1 0.219052 $8.1100 $37.0100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 1.632725 $79.1900 $48.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.583333 $29.7800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 7 6.966667 $355.6500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.161111 $8.2200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 6.172222 $315.0900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.511111 $26.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 4.681746 $239.0100 $51.0500
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Subtotal (Total Children Is Unduplicated) 19 24 20.708915 $1053.0300 $50.8500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 31 26.579363 $1328.9600 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 3 8 2.194443 $109.7200 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 9.571429 $239.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 48 54 441.668754 $22083.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 980 1231 10308.321176 $103083.3800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 60.571428 $4327.2300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 39.500000 $2821.8700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 6 38.785715 $2770.8400 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 1 8.285714 $4.1400 $0.5000
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Subtotal (Total Children Is Unduplicated) 1000 1348 10935.478022 $136768.9100 $12.5100
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Total 1373 10956.405989 $137830.0400 $12.5800
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Number of Children (Unduplicated) With at Least One Authorization 1007