Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 3264 FSPSA's found of which 234 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 15 19 77.663495 $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) 16 20 77.770638 $3.9600 $0.0500
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 16 18 5.963471 $289.2300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 4.622221 $217.6500 $47.0900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.355556 $7.8100 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.411111 $26.7800 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 0.698554 $17.8400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 10.500793 $491.4400 $46.8000
EXIT -EXIT EXIT ASSESSMENT 36 42 51.203198 $2560.1600 $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 3 5 3.649999 $273.7500 $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 3 4 0.727778 $54.5900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 0.693798 $38.5100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 2 0.756165 $56.7200 $75.0000
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
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 2 0.756165 $56.7200 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.800000 $40.8400 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 14 14 13.941531 $2091.2100 $150.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 3.569559 $182.2300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.043836 $2.2400 $51.0100
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Subtotal (Total Children Is Unduplicated) 111 133 101.043276 $6538.7800 $64.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 22 5.957763 $29789.0000 $5000.0300
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 11.022222 $789.3000 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 40 23.340641 $1167.0400 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 273 353 422.044260 $21102.2200 $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 8 9 52.499999 $2625.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 710 949 5976.031297 $298801.8200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 501 1030 5558.213889 $55582.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 7 48.504763 $3465.1800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 30 38 252.885712 $18066.1800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 6.571429 $375.6200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 63 448.560497 $32045.1800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 17.571428 $243.8900 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 334 556 3780.727291 $1890.3600 $0.5000
TRAV -TRAVS Travel by mile 20 37 141.861903 $63.1300 $0.4400
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Subtotal (Total Children Is Unduplicated) 760 3111 16747.626427 $466051.9000 $27.8300
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Total 3264 16926.440341 $472594.6400 $27.9200
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Number of Children (Unduplicated) With at Least One Authorization 764