Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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 2468 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 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 19 21 7.299999 $372.6800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.534322 $78.3300 $51.0500
SCREEN-T1023 SCREENING 31 32 13.323061 $666.1600 $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 29 29 11.982342 $611.6900 $51.0500
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Subtotal (Total Children Is Unduplicated) 81 109 48.440788 $2031.1300 $41.9300
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 83 48.536166 $2426.8200 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 290 805 1860.810244 $93040.7600 $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 287 361 2203.653749 $110182.7700 $50.0000
INTR -T1013 INTERPRETER 7 10 50.576193 $2528.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 2 2.133334 $21.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 75 97 605.388093 $43248.9300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 21 132.946428 $7604.5300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 76 92 529.255164 $37809.9900 $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 186 240 1529.777382 $109287.3600 $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 33 50 648.030158 $288.3700 $0.4400
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Subtotal (Total Children Is Unduplicated) 490 2355 13888.333651 $420375.7300 $30.2700
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Total 2468 13940.602587 $422548.4900 $30.3100
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Number of Children (Unduplicated) With at Least One Authorization 498