Summary Report for FSPSAs Ending During the Report Period Center: 05
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 578 FSPSA's found of which 18 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 0.466667 $17.2700 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.466667 $17.2700 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 13 13 2.190488 $109.5300 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 0.613851 $46.0400 $74.9900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.202740 $15.2000 $74.9900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.242466 $18.1900 $75.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 5.067450 $258.7000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 2.278995 $116.3400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 1.361644 $69.5100 $51.0500
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Subtotal (Total Children Is Unduplicated) 37 41 11.957634 $633.5100 $52.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.098630 $493.0000 $4998.4800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 10.209133 $510.4600 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 51 93 112.180833 $5609.0400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 21.857143 $546.4300 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 0.202740 $10.1400 $49.9900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 140 154 788.314292 $39415.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 89 126 597.811109 $5978.1200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 19 102.021429 $7288.4100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 26 26 123.857143 $8848.3600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 66 72 366.238099 $26164.0100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 20 25 156.212697 $78.1100 $0.5000
TRAV -TRAVS Travel by mile 1 1 4.857143 $2.1600 $0.4400
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Subtotal (Total Children Is Unduplicated) 167 536 2283.860391 $94943.9100 $41.5700
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Total 578 2296.284692 $95594.6900 $41.6300
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Number of Children (Unduplicated) With at Least One Authorization 181