Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 2339 FSPSA's found of which 13 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 10 11 987.307936 $36530.3900 $37.0000
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Subtotal (Total Children Is Unduplicated) 10 11 987.307936 $36530.3900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 4 1.947641 $91.7200 $47.0900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 13 2.268493 $19.8500 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 14 2.350685 $51.3500 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.175342 $11.4200 $65.1200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 2.241096 $51.3300 $22.9000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 6 3.304566 $154.6500 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 5 3.170319 $379.1700 $119.6000
EXIT -EXIT EXIT ASSESSMENT 34 38 2.232497 $111.6200 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 13.142858 $985.7100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 0.016438 $1.2300 $74.8300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 16 0.057536 $3.1700 $55.0700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 13 0.041098 $3.0500 $74.2700
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 0.464917 $23.7300 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 0.221917 $33.2900 $149.9900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.428571 $21.8800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 13.762112 $702.5600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.432115 $22.0600 $51.0500
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Subtotal (Total Children Is Unduplicated) 85 148 46.258201 $2667.7700 $57.6700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071233 $356.0000 $4997.6800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 5.994216 $299.7100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.005556 $0.4000 $72.1700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.117808 $28.1800 $239.1800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 62 78 80.875615 $4043.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 115 220 721.147623 $36057.4300 $50.0000
CONIP -CONIP CONSULT, PHONE 3 5 14.295237 $357.3800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.285714 $82.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 823 1051 9136.189398 $456810.0000 $50.0000
INTR -T1013 INTERPRETER 6 6 63.434051 $3171.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 54 58 505.072145 $5050.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 77.428571 $5531.5100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $187.9400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 9 10 75.933338 $5424.6900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 7.285714 $416.4500 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.642542 $152.3700 $237.1400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.082192 $38.9800 $474.2900
SENS -V5264 EARMOLD 3 4 3.153881 $56.7700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 53 430.273811 $30738.8000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 2 11.285714 $156.6500 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 526 644 5592.837773 $2796.4100 $0.5000
TRAV -TRAVS Travel by mile 22 25 158.862622 $70.6900 $0.4400
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Subtotal (Total Children Is Unduplicated) 854 2180 16891.566024 $551828.8600 $32.6700
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Total 2339 17925.132161 $591027.0200 $32.9700
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Number of Children (Unduplicated) With at Least One Authorization 870