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 776 FSPSA's found of which 87 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
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Subtotal (Total Children Is Unduplicated) 4 5 14.635715 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 0.391477 $18.9900 $48.5000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.505555 $12.9100 $25.5300
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 1 1 1.033333 $77.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.019179 $1.0700 $55.5700
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 11 11 12.415199 $1862.2700 $150.0000
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Subtotal (Total Children Is Unduplicated) 34 42 50.986847 $3805.6600 $74.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.117808 $589.0000 $4999.6600
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
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 9 10 40.398412 $2019.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 221 311 1596.763734 $15967.6400 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 8 8 58.576190 $4184.6800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 12 62.142857 $4439.4800 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 183 294 1419.934178 $709.9700 $0.5000
TRAV -TRAVS Travel by mile 5 11 19.925398 $8.8700 $0.4400
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Subtotal (Total Children Is Unduplicated) 370 729 3300.950998 $33074.1700 $10.0200
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Total 776 3366.573560 $36879.8300 $10.9500
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Number of Children (Unduplicated) With at Least One Authorization 378