Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 2582 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
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 9 9 8.488028 $424.4100 $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 36 41 387.316666 $29048.7500 $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 37 40 35.542854 $1972.6100 $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) 117 207 656.018771 $45393.3700 $69.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 9 2.784323 $13921.5000 $4999.9600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 44 45 15.339855 $766.9900 $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 38 50 139.639137 $6981.9500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.266667 $6.6700 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 157 218 304.901585 $15245.0700 $50.0000
CONIP -CONIP CONSULT, PHONE 15 19 18.344445 $458.6100 $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 587 831 5888.919746 $294446.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 440 768 4113.468210 $41134.7100 $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) 595 2360 16731.697453 $378457.7700 $22.6200
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Total 2582 17460.756700 $424887.1300 $24.3300
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Number of Children (Unduplicated) With at Least One Authorization 603