Summary Report for FSPSAs Ending During the Report Period Center: 57
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 1615 FSPSA's found of which 7 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 5 5 1.481852 $54.8300 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5 5 1.481852 $54.8300 $37.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 2.928571 $162.5400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 12 3.928570 $294.6600 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 2.333788 $119.1300 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 29 7.541800 $384.9900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 16 8.584473 $438.2300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 23 6.283333 $320.7600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 58 24.311252 $1241.1000 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 120 155 57.911787 $3111.4100 $53.7300
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 162 207 124.691278 $6234.6100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 24 166.571426 $4164.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 312 323 2271.912701 $113595.6500 $50.0000
INTR -T1013 INTERPRETER 1 1 1.285714 $64.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 340 727 2521.818889 $25218.2000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 40 154.821429 $11060.4400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.571429 $261.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 43 43 212.395239 $15173.5100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 29.928572 $1710.7100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 57 250.857143 $17921.2600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 10 12 139.140476 $69.5700 $0.5000
TRAV -TRAVS Travel by mile 13 15 95.000002 $42.2800 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 422 1455 5976.422869 $195712.3900 $32.7500
-------------------------------------------------------------------------------------------------------------------------------------
Total 1615 6035.816508 $198878.6400 $32.9500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 438