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 1616 FSPSA's found of which 58 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 3 4 4.700000 $173.9000 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 4 4.700000 $173.9000 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 52 55 12.101603 $605.0900 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 10.553968 $791.5500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.235616 $17.6700 $74.9900
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 3 3 0.282192 $14.4100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.597261 $30.4900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 0.849314 $43.3700 $51.0600
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Subtotal (Total Children Is Unduplicated) 64 73 32.855570 $2100.7500 $63.9400
EI Services, Class # 03
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 14 16 113.285713 $2832.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 271 1980.099585 $99005.1700 $50.0000
INTR -T1013 INTERPRETER 5 5 60.209524 $3010.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 239 355 2525.128386 $25251.3400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 12 87.511938 $6251.8600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 10 96.999999 $6929.6900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 54 393.802380 $28133.2800 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 138 183 1713.557544 $856.7800 $0.5000
TRAV -TRAVS Travel by mile 3 6 28.320417 $12.6000 $0.4400
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Subtotal (Total Children Is Unduplicated) 476 1539 7758.131522 $210167.5200 $27.0900
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Total 1616 7795.687092 $212442.1700 $27.2500
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Number of Children (Unduplicated) With at Least One Authorization 488