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
Eligibility Filter: Program Patients
With the filters selected there were 2649 FSPSA's found of which 64 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 4 5 5.166667 $191.1700 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 5 5.166667 $191.1700 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 53 56 12.413932 $620.7100 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 10.756708 $806.7500 $75.0000
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 2 2 0.478082 $35.8600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.000000 $55.5000 $55.5000
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 39 40 9.486630 $484.3200 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.194521 $9.9300 $51.0400
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 4.503653 $229.9100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 65 66 25.013416 $1276.9700 $51.0500
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Subtotal (Total Children Is Unduplicated) 156 191 71.285298 $4077.8300 $57.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 1.484932 $7425.0000 $5000.2300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.282192 $14.1100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 56 84 87.686324 $4384.3200 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 211 542 668.463045 $33423.1800 $50.0000
CONIP -CONIP CONSULT, PHONE 1 1 3.066667 $76.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 25 190.466667 $4761.6800 $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 469 619 4459.571007 $222978.9000 $50.0000
INTR -T1013 INTERPRETER 5 5 60.209524 $3010.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 239 356 2532.556957 $25325.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 100 688.242630 $49168.0900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 14.714285 $841.6600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 116 140 993.428571 $70970.6000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 280 364 2646.245240 $189047.9200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 55.247618 $766.8400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 139 184 1725.414687 $862.7100 $0.5000
TRAV -TRAVS Travel by mile 3 6 28.320417 $12.6000 $0.4400
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Subtotal (Total Children Is Unduplicated) 540 2453 14155.603503 $613080.5000 $43.3100
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Total 2649 14232.055468 $617349.4900 $43.3800
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Number of Children (Unduplicated) With at Least One Authorization 550