Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 2244 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
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 9 10 15.834594 $808.3500 $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 11 13 9.292064 $474.3600 $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 33 35 28.079887 $1433.4900 $51.0500
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Subtotal (Total Children Is Unduplicated) 262 465 72.876582 $4829.9900 $66.2800
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 101 117 901.389229 $45069.5300 $50.0000
INTR -T1013 INTERPRETER 2 2 2.972146 $148.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 9 15 171.571426 $1715.7200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 136 201 1128.305562 $80606.0900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 46 52 350.806747 $20066.1500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 120 192 1127.247627 $80530.4900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 25 30 179.573412 $10264.4200 $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 395 531 3738.955329 $267111.1500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 18.446032 $256.0300 $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) 578 1745 11088.759735 $519961.8400 $46.8900
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Total 2244 11183.964091 $525617.9400 $47.0000
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Number of Children (Unduplicated) With at Least One Authorization 692