Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 1056 FSPSA's found of which 39 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 3 3.000000 $111.0000 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 26.609524 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 25.000000 $925.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 6 9 54.609524 $1036.0000 $18.9700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 64.000000 $3104.0000 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.338889 $15.8600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.338889 $40.5300 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 4 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 9 9 8.488028 $424.4100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.966667 $72.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 4.433333 $332.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 9 42.966667 $3222.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 22 47.633105 $3572.4800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 10.153968 $563.5500 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 26 47.505479 $2636.5600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 6.043834 $453.3000 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.433334 $215.0100 $150.0100
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Subtotal (Total Children Is Unduplicated) 68 97 246.307672 $15303.6100 $62.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 0.839879 $4199.5000 $5000.1300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 3 1.711110 $85.5500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 30 24.889682 $1244.4900 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 62 69 97.169050 $4858.4600 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 4.977778 $124.4500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.444444 $32.5800 $73.3100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 24.285715 $607.1400 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 2.000000 $100.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 298 338 1945.472145 $97273.6300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 183 240 960.493627 $9604.9400 $10.0000
SENS -V5264 EARMOLD 2 2 0.500000 $9.0000 $18.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 155 247 1335.039833 $667.5200 $0.5000
TRAV -TRAVS Travel by mile 5 6 1588.442857 $706.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 335 950 5986.266120 $119514.1000 $19.9600
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Total 1056 6287.183316 $135853.7100 $21.6100
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Number of Children (Unduplicated) With at Least One Authorization 358