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 2224 FSPSA's found of which 161 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
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Subtotal (Total Children Is Unduplicated) 15 19 77.663495 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 5.963471 $289.2300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 2.238888 $105.4300 $47.0900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.446499 $11.4000 $25.5300
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 2 2 1.083333 $81.2500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.050000 $3.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.019179 $1.0700 $55.5700
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.252055 $18.9100 $75.0100
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.252055 $18.9100 $75.0100
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 13 13 13.941531 $2091.2100 $150.0000
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) 79 91 75.788337 $5200.0900 $68.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 1.858980 $9295.0000 $5000.0500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 10.000000 $716.1000 $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
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 19 24 135.041268 $6752.0700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 501 1030 5558.213889 $55582.1600 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 13 17 117.633332 $8403.7400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 42 290.708116 $20768.2200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.285714 $115.0100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 333 553 3762.441577 $1881.2200 $0.5000
TRAV -TRAVS Travel by mile 20 37 141.861903 $63.1300 $0.4400
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Subtotal (Total Children Is Unduplicated) 752 2114 10523.929679 $128470.8800 $12.2100
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Total 2224 10677.381511 $133670.9600 $12.5200
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Number of Children (Unduplicated) With at Least One Authorization 756