Summary Report for FSPSAs Initiated During the Report Period Center: 06
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 2368 FSPSA's found of which 17 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 58 60 114.707232 $4244.2000 $37.0000
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Subtotal (Total Children Is Unduplicated) 58 60 114.707232 $4244.2000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 5.500000 $257.4000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 14 12.214156 $1460.8300 $119.6000
EXIT -EXIT EXIT ASSESSMENT 4 4 0.356165 $17.8100 $49.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.164384 $8.3900 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.288889 $193.3400 $150.0000
SCREEN-T1023 SCREENING 15 16 10.166666 $508.3300 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.131507 $2.0500 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.213698 $10.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 33 41 30.035465 $2459.0500 $81.8700
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 6.773015 $338.6500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 11.417460 $570.8800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.128767 $30.8100 $239.2600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 97 101 23.842120 $1192.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 0.705555 $17.6400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 49 114 164.114288 $8205.7400 $50.0000
CONIP -CONIP CONSULT, PHONE 11 29 40.633333 $1015.8300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 68.571429 $1714.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 69 82 1382.762357 $34569.0600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 440 556 4112.947629 $205647.6700 $50.0000
INTR -T1013 INTERPRETER 24 26 126.833527 $6341.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 602 922 6301.366863 $63013.7500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 69 263.007144 $18789.2100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 14 17 65.957143 $3772.7500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 85 105 314.142865 $22442.3000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 40 49 157.034920 $8976.1000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 3.894064 $253.1200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.216438 $25.6600 $118.5400
SENS -V5050 IN EAR MONAURAL HEARING AID 9 9 7.261645 $1721.9200 $237.1300
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.131507 $31.1800 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.128767 $61.0800 $474.3600
SENS -V5264 EARMOLD 26 33 51.926072 $934.6700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 99 114 503.785722 $35990.4400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 60.857143 $844.7000 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.133333 $0.0600 $0.4400
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Subtotal (Total Children Is Unduplicated) 700 2267 13716.573106 $416525.3300 $30.3700
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Total 2368 13861.315803 $423228.5800 $30.5300
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Number of Children (Unduplicated) With at Least One Authorization 764