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 1515 FSPSA's found of which 46 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
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Subtotal (Total Children Is Unduplicated) 6 13 48.040476 $111.0000 $2.3100
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 8 8 8.082549 $404.1300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 2.033333 $152.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 5.066667 $380.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 8 3.649999 $273.7400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.011111 $56.1200 $55.5000
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) 26 32 100.143660 $5333.9400 $53.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.261111 $1305.5000 $4999.7900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 42 43 14.773188 $738.6500 $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 1 1 2.571429 $64.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 21 207.607143 $10380.3600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 425 736 3884.305590 $38843.0800 $10.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 239 383 2964.062056 $1482.0300 $0.5000
TRAV -TRAVS Travel by mile 6 7 3148.442857 $1401.0600 $0.4500
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Subtotal (Total Children Is Unduplicated) 571 1470 10580.841876 $71807.6200 $6.7900
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Total 1515 10729.026012 $77252.5700 $7.2000
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Number of Children (Unduplicated) With at Least One Authorization 574