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
Eligibility Filter: Program Patients
With the filters selected there were 634 FSPSA's found of which 22 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 3.033333 $112.2300 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 3.033333 $112.2300 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 31 31 6.909209 $345.4700 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.411111 $30.8300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.235616 $17.6700 $74.9900
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 7.235616 $542.6700 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.076712 $3.9200 $51.1100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.246575 $12.5900 $51.0800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 0.339726 $17.3500 $51.0800
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Subtotal (Total Children Is Unduplicated) 40 45 15.454565 $970.5000 $62.8000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 21 14.131356 $706.5800 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 81 149 197.383219 $9869.1800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 74.714287 $1867.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 110 125 748.183727 $37409.2100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 141 202 1105.845855 $11058.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 4 28.411938 $2029.7500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 19.857143 $1418.5900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 26 140.907143 $10066.4200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 40 47 267.956291 $133.9800 $0.5000
TRAV -TRAVS Travel by mile 2 2 14.000000 $6.2300 $0.4500
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Subtotal (Total Children Is Unduplicated) 241 588 2611.390959 $74566.2400 $28.5500
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Total 634 2629.878857 $75648.9800 $28.7700
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Number of Children (Unduplicated) With at Least One Authorization 256