Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 2504 FSPSA's found of which 57 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 10 45.040476 $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 15 73.040476 $1036.0000 $14.1800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 64.000000 $3104.0000 $48.5000
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.511111 $19.6100 $38.3700
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 8 8 8.082549 $404.1300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 1.288889 $96.6700 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 11 9.488887 $711.6500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 35 40 385.783333 $28933.7500 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.383333 $28.7500 $74.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 25 51 73.588654 $5519.1000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 35 37 32.476188 $1802.4200 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 4 2.466590 $185.0000 $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 26 27 47.922146 $2659.6800 $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
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 4.866667 $248.4500 $51.0500
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Subtotal (Total Children Is Unduplicated) 115 202 651.013293 $45087.9000 $69.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 8 2.273212 $11366.0000 $4999.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 43 44 14.828744 $741.4300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.444444 $31.8200 $71.6000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 49 47.639137 $2381.9500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.266667 $6.6700 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 150 207 289.634920 $14481.7400 $50.0000
CONIP -CONIP CONSULT, PHONE 14 18 17.322223 $433.0600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 3.511111 $257.4300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 87.761906 $2194.0500 $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 569 804 5628.878478 $281444.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 426 737 3897.448447 $38974.5000 $10.0000
SENS -V5264 EARMOLD 2 2 0.500000 $9.0000 $18.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 242 390 3005.373167 $1502.6900 $0.5000
TRAV -TRAVS Travel by mile 6 7 3148.442857 $1401.0600 $0.4500
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Subtotal (Total Children Is Unduplicated) 582 2287 16146.325313 $355325.5400 $22.0100
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Total 2504 16870.379082 $401449.4400 $23.8000
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Number of Children (Unduplicated) With at Least One Authorization 590