Summary Report for FSPSAs Ending During the Report Period Center: 54
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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1196 FSPSA's found of which 124 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 5 14.635715 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.107143 $3.9600 $36.9900
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Subtotal (Total Children Is Unduplicated) 5 6 14.742858 $3.9600 $0.2700
Screening, Eval, and Assessment, Class # 02
AACIO -92597GO AAC INITIAL EVAL BY LICENSED OT 1 1 0.005479 $0.5600 $103.0300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 0.391477 $18.9900 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.355556 $7.8100 $21.9500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.505555 $12.9100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.733333 $34.3200 $46.8000
EXIT -EXIT EXIT ASSESSMENT 15 20 36.327812 $1816.3900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.010959 $0.8300 $75.2800
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 0.283333 $15.7200 $55.4900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 3 3.499999 $262.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.066667 $5.0000 $75.0400
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 0.666401 $36.9900 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 2.038812 $113.1500 $55.5000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 11 11 12.415199 $1862.2700 $150.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 3.002892 $153.3000 $51.0500
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Subtotal (Total Children Is Unduplicated) 48 60 60.314432 $4341.5500 $71.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 0.156241 $781.5000 $5001.8900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 13 8.613852 $430.7000 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 59 66 75.545236 $3777.2600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.833333 $45.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 18.933333 $946.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 341 384 1845.222587 $92261.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 221 311 1596.763734 $15967.6400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 9.714286 $693.9900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 17 17 104.404761 $7458.6900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 22 135.857144 $9705.6200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 184 297 1438.219892 $719.1100 $0.5000
TRAV -TRAVS Travel by mile 5 11 19.925398 $8.8700 $0.4400
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Subtotal (Total Children Is Unduplicated) 383 1130 5255.189797 $132796.9500 $25.2700
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Total 1196 5330.247087 $137142.4700 $25.7300
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Number of Children (Unduplicated) With at Least One Authorization 394