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
Eligibility Filter: Program Patients
With the filters selected there were 3626 FSPSA's found of which 20 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 6 6 7.083703 $262.0900 $37.0000
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Subtotal (Total Children Is Unduplicated) 6 6 7.083703 $262.0900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 7 9.418721 $98.1400 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 8 12.418721 $108.6600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 7 9.418721 $205.7000 $21.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 7 11.685388 $298.3300 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 0.649315 $30.3900 $46.8100
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.142466 $17.0400 $119.6300
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.663775 $33.1900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 1.166666 $58.3300 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.633334 $83.3900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 33 12.249771 $625.3600 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.066667 $10.0100 $150.0700
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 7.931147 $404.8800 $51.0500
SCREEN-T1023 SCREENING 43 44 17.084628 $854.2300 $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 49 50 21.621231 $1103.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 126 183 106.208085 $3934.3500 $37.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.855556 $9278.0000 $5000.1200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 8 16.100000 $805.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 93 122 65.496812 $3274.8500 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 409 1150 2673.615020 $133681.0800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 5 19.169842 $958.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 383 488 3050.112811 $152505.7700 $50.0000
INTR -T1013 INTERPRETER 7 10 50.576193 $2528.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 4 34.552381 $345.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 107 144 845.387296 $60394.4700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 23 27 154.794048 $8854.2200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 118 155 935.788498 $66852.7300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 40.523810 $2316.3500 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.131507 $31.1800 $237.1100
SENS -V5264 EARMOLD 6 8 7.366667 $132.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 310 398 2574.310715 $183908.8300 $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 439 816 8719.558046 $4359.7700 $0.5000
TRAV -TRAVS Travel by mile 64 91 1069.068249 $475.7300 $0.4400
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Subtotal (Total Children Is Unduplicated) 714 3437 20265.550308 $630802.5400 $31.1300
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Total 3626 20378.842096 $634998.9800 $31.1600
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Number of Children (Unduplicated) With at Least One Authorization 724