Summary Report for FSPSAs Ending During the Report Period Center: 55
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 1183 FSPSA's found of which 1 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
TCM -T1017TL TARGETED CASE MANAGEMENT 12 12 4.338888 $160.5400 $37.0000
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Subtotal (Total Children Is Unduplicated) 12 12 4.338888 $160.5400 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.145206 $6.8000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.312786 $276.6200 $119.6100
EVAL -96111 DEVELOPMENTAL EVALUATION 3 4 0.175342 $8.7700 $50.0200
EXIT -EXIT EXIT ASSESSMENT 4 4 0.079453 $3.9700 $49.9700
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 0.027395 $2.0600 $75.2900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 0.016437 $1.2400 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.010958 $0.6100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 161 165 3.375284 $253.4200 $75.0800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 66 66 0.496027 $37.3300 $75.2500
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 43 43 0.232858 $17.5300 $75.2700
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 38 38 0.293288 $16.3200 $55.6300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 46 46 0.583543 $43.8300 $75.1100
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 15.597988 $796.2700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 0.612710 $31.2800 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 6.066667 $910.0100 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 5.883333 $300.3400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.437747 $22.3400 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 23 19.593826 $1000.2700 $51.0500
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Subtotal (Total Children Is Unduplicated) 233 427 55.951806 $3729.8300 $66.6600
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.466667 $73.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 15 2.940488 $147.0300 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 18 26 18.316664 $915.8200 $50.0000
CONIP -CONIP CONSULT, PHONE 14 25 32.497221 $812.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 17.714286 $442.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 37 39 253.495236 $12674.7700 $50.0000
INTR -T1013 INTERPRETER 2 2 2.972146 $148.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 4 26.999999 $270.0000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 93 528.911902 $37785.4800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 17 18 98.816666 $5652.3000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 72 94 492.278577 $35168.3300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 52.492857 $3000.4900 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.756164 $179.3100 $237.1300
SENS -V5264 EARMOLD 4 4 3.166667 $57.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 194 221 1361.855546 $97291.0100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.785714 $135.8300 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 121 176 992.621865 $496.3100 $0.5000
TRAV -TRAVS Travel by mile 6 9 60.252382 $26.8100 $0.4500
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Subtotal (Total Children Is Unduplicated) 302 744 3957.341047 $195277.7100 $49.3500
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Total 1183 4017.631741 $199168.0800 $49.5700
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Number of Children (Unduplicated) With at Least One Authorization 490