Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 5489 FSPSA's found of which 1091 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 13 13 9.877777 $365.4700 $37.0000
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Subtotal (Total Children Is Unduplicated) 13 13 9.877777 $365.4700 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 213 214 95.546493 $1426.5000 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 187 190 79.849676 $1533.1200 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 211 213 94.363160 $983.2600 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 209 210 93.524272 $818.3300 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 1.250000 $10.0800 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 209 212 93.457604 $2041.1000 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 107 108 47.218721 $3075.8300 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 206 206 91.368716 $2092.3300 $22.9000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 16 8.683334 $443.2900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.844444 $94.1600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 33 33 33.279367 $1698.9200 $51.0500
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Subtotal (Total Children Is Unduplicated) 323 1411 640.385787 $14216.9000 $22.2000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 13 4.684720 $234.2300 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 166 341 278.753974 $13937.7300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 862 1115 10346.083693 $517304.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 868 1746 1356.344141 $13563.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 183 215 1428.084944 $102022.3900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.071429 $290.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 302 353 1983.505596 $141701.6000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 5.142858 $293.9600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 247 278 1955.816679 $139723.6000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.785714 $24.7900 $13.8800
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Subtotal (Total Children Is Unduplicated) 1156 4065 17365.273748 $929096.3800 $53.5000
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Total 5489 18015.537312 $943678.7600 $52.3800
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Number of Children (Unduplicated) With at Least One Authorization 1175