Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 2509 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 61 64 121.762788 $4505.2500 $37.0000
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Subtotal (Total Children Is Unduplicated) 61 64 121.762788 $4505.2500 $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 11 15 12.307307 $1471.9800 $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 16 17 11.188888 $559.4400 $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) 35 43 31.150838 $2521.3100 $80.9400
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 6.773015 $338.6500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 13 18.117460 $905.8800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.380822 $91.1100 $239.2500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 101 105 26.598072 $1329.9600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 0.705555 $17.6400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 53 122 188.647624 $9432.4200 $50.0000
CONIP -CONIP CONSULT, PHONE 11 29 40.633333 $1015.8300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 173.714287 $4342.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 72 90 1644.476643 $41111.9100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 462 583 4415.723818 $220786.5100 $50.0000
INTR -T1013 INTERPRETER 26 28 159.252574 $7962.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 630 969 6747.704959 $67477.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 73 280.969049 $20072.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 15 18 70.557143 $4035.8700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 90 111 335.425007 $23962.6800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 45 54 182.799205 $10448.7900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 4.146119 $269.5000 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.216438 $25.6600 $118.5400
SENS -V5050 IN EAR MONAURAL HEARING AID 10 10 7.354796 $1744.0200 $237.1300
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.131507 $31.1800 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 3 3 0.380822 $180.6400 $474.3400
SENS -V5264 EARMOLD 27 37 55.892739 $1006.0700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 119 525.428580 $37536.6000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 83.638096 $1160.9000 $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) 730 2402 15017.800996 $455310.8900 $30.3200
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Total 2509 15170.714622 $462337.4600 $30.4800
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Number of Children (Unduplicated) With at Least One Authorization 798