Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2174 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 30 34 22.327774 $826.1100 $37.0000
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Subtotal (Total Children Is Unduplicated) 30 34 22.327774 $826.1100 $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 8 9 5.698174 $681.5200 $119.6000
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 6 6 0.138506 $10.4000 $75.0500
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 0.075341 $5.6600 $75.0600
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 8 9 15.645705 $798.7100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 1.545130 $78.8800 $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 10 12 8.780953 $448.2700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 0.743302 $37.9400 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 30 32 26.746554 $1365.4200 $51.0500
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Subtotal (Total Children Is Unduplicated) 259 460 70.843249 $4726.1900 $66.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.450000 $2250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.466667 $73.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.022222 $51.1100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 28 11.543455 $577.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 7 5.383334 $134.5900 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 49 98 112.051629 $5602.5800 $50.0000
CONIP -CONIP CONSULT, PHONE 34 72 123.449602 $3086.2400 $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 99 114 863.960658 $43198.1000 $50.0000
INTR -T1013 INTERPRETER 2 2 2.972146 $148.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 3 39.428571 $394.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 130 193 1068.019848 $76299.2700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 43 49 324.521032 $18562.6100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 114 185 1050.354770 $75037.2600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 23 28 153.287698 $8761.9200 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 1.008219 $239.0900 $237.1400
SENS -V5264 EARMOLD 8 10 8.233333 $148.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 372 502 3435.169614 $245408.6700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 11.874603 $164.8200 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 248 363 3094.554398 $1547.2700 $0.5000
TRAV -TRAVS Travel by mile 7 13 92.615080 $41.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 552 1680 10419.081165 $482169.1900 $46.2800
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Total 2174 10512.252188 $487721.4900 $46.4000
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Number of Children (Unduplicated) With at Least One Authorization 668