Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 2404 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 3.828148 $141.6400 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.828148 $141.6400 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.285388 $34.2300 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.285388 $28.7500 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.285388 $71.7500 $21.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.585388 $66.0100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.317808 $14.8800 $46.8100
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.131507 $15.7300 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.008219 $0.4100 $49.8800
EXIT -EXIT EXIT ASSESSMENT 3 3 0.988888 $49.4400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.355556 $18.1500 $51.0600
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 18 5.211110 $266.0400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.534322 $78.3300 $51.0500
SCREEN-T1023 SCREENING 27 28 9.450001 $472.5000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.057534 $2.9400 $51.0200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 28 28 11.471231 $585.5900 $51.0500
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Subtotal (Total Children Is Unduplicated) 75 101 41.967728 $1704.7400 $40.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.566667 $7833.5000 $5000.1100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 6.100000 $305.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 65 82 45.469499 $2273.4800 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 284 780 1785.305476 $89265.4900 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 12.409524 $620.4800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 274 348 2083.244225 $104162.2800 $50.0000
INTR -T1013 INTERPRETER 6 8 36.766669 $1838.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 2 2.133334 $21.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 92 516.816666 $36921.3900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 21 132.946428 $7604.5300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 74 90 509.978974 $36432.9000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 33.523810 $1916.2300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.131507 $31.1800 $237.1100
SENS -V5264 EARMOLD 3 3 1.277777 $23.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 180 233 1443.063096 $103092.5000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 7.142857 $99.1400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 307 577 6215.074598 $3107.5300 $0.5000
TRAV -TRAVS Travel by mile 32 49 621.744444 $276.6800 $0.4400
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Subtotal (Total Children Is Unduplicated) 476 2299 13454.695551 $395824.9700 $29.4200
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Total 2404 13500.491427 $397671.3500 $29.4600
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Number of Children (Unduplicated) With at Least One Authorization 485