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 807 FSPSA's found of which 39 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
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 1 1 0.411111 $30.8300 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.197260 $10.0700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.605479 $30.9200 $51.0600
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Subtotal (Total Children Is Unduplicated) 31 33 6.185770 $320.4200 $51.8000
EI Services, Class # 03
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 4 4 41.000000 $1025.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 28 210.544441 $10527.2400 $50.0000
INTR -T1013 INTERPRETER 5 5 60.209524 $3010.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 150 218 1428.020628 $14280.2400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 4.571429 $326.5800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 23.285714 $1663.5400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 94.390476 $6743.2600 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 77 106 985.604428 $492.8000 $0.5000
TRAV -TRAVS Travel by mile 2 4 15.177560 $6.7500 $0.4400
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Subtotal (Total Children Is Unduplicated) 271 774 3318.084515 $60763.2500 $18.3100
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Total 807 3324.270285 $61083.6700 $18.3800
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Number of Children (Unduplicated) With at Least One Authorization 279