Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 1561 FSPSA's found of which 44 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 28 28 4.971920 $248.6000 $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 31 32 8.445533 $431.1600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 3.618721 $184.7400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 44 44 7.244141 $369.8300 $51.0500
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Subtotal (Total Children Is Unduplicated) 100 122 25.339372 $1313.7600 $51.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 0.909589 $4548.5000 $5000.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 42 67 73.708545 $3685.4300 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 127 328 378.505103 $18925.2700 $50.0000
CONIP -CONIP CONSULT, PHONE 1 1 3.066667 $76.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 118.180954 $2954.5300 $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 287 374 2672.730149 $133636.6800 $50.0000
INTR -T1013 INTERPRETER 5 5 60.209524 $3010.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 150 219 1435.449199 $14354.5300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 51 338.230692 $24163.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 9.428571 $539.3200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 67 79 553.549999 $39545.6600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 141 180 1300.890477 $92935.6800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 16.000000 $222.0800 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 78 107 997.461571 $498.7300 $0.5000
TRAV -TRAVS Travel by mile 2 4 15.177560 $6.7500 $0.4400
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Subtotal (Total Children Is Unduplicated) 320 1438 7973.701340 $339113.6200 $42.5300
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Total 1561 7999.507379 $340444.6500 $42.5600
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Number of Children (Unduplicated) With at Least One Authorization 326