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 744 FSPSA's found of which 33 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
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Subtotal (Total Children Is Unduplicated) 6 8 29.615080 $111.0000 $3.7500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 64.000000 $3104.0000 $48.5000
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 -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.011111 $75.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.477778 $35.8400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 6 2.122145 $159.1600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.011111 $56.1200 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 2 2.133334 $160.0100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 2.500000 $138.7500 $55.5000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.433334 $215.0100 $150.0100
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Subtotal (Total Children Is Unduplicated) 24 33 106.811365 $5550.8400 $51.9700
EI Services, Class # 03
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 2 2 4.171429 $104.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 18 55.407143 $2770.3600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 214 283 1128.028550 $11280.2900 $10.0000
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 166 263 1366.807295 $683.4000 $0.5000
TRAV -TRAVS Travel by mile 6 7 1588.448413 $706.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 364 703 4314.085632 $23906.1600 $5.5400
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Total 744 4450.512077 $29568.0000 $6.6400
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Number of Children (Unduplicated) With at Least One Authorization 373