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
Eligibility Filter: Program Patients
With the filters selected there were 1211 FSPSA's found of which 43 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 5 5 26.615080 $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) 7 10 54.615080 $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 2 2 0.661111 $79.0700 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 4 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 11 12 22.122552 $1106.1400 $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 6 6 67.055555 $5029.1600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 12 43.611111 $3270.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 25 51.438584 $3857.9000 $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 3 5 4.449925 $333.7600 $75.0000
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 27 28 50.005479 $2775.3100 $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) 80 116 336.281009 $21676.3800 $64.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 0.839879 $4199.5000 $5000.1300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 4 5.996824 $299.8400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 35 25.796608 $1289.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 0.327778 $8.2000 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 74 83 130.523814 $6526.2100 $50.0000
CONIP -CONIP CONSULT, PHONE 2 3 5.633334 $140.8400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.444444 $32.5800 $73.3100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 34.314287 $857.8500 $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 333 377 2143.057860 $107152.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 215 285 1138.599978 $11386.0000 $10.0000
SENS -V5264 EARMOLD 2 2 0.500000 $9.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 0.500000 $35.7200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.000000 $27.7600 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 169 269 1393.480311 $696.7400 $0.5000
TRAV -TRAVS Travel by mile 6 7 1588.448413 $706.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 381 1085 6472.463530 $133469.8400 $20.6200
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Total 1211 6863.359619 $156182.2100 $22.7600
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Number of Children (Unduplicated) With at Least One Authorization 406