Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 3833 FSPSA's found of which 9 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 13 13 5.119259 $189.4000 $37.0000
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Subtotal (Total Children Is Unduplicated) 13 13 5.119259 $189.4000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 0.705556 $45.9600 $65.1400
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 -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.488889 $36.6700 $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 12 13 4.417459 $331.3300 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 17 20 7.128233 $363.8900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 74 81 48.384654 $2470.0100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 31 37 25.000019 $1276.2400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 43 44 22.691266 $1158.3700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 123 132 115.812040 $5912.1900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 22.642064 $1155.8800 $51.0500
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Subtotal (Total Children Is Unduplicated) 242 344 252.198751 $13063.0800 $51.8000
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.322222 $77.0700 $239.1800
CONIF -CONIF CONSULT, FACE TO FACE 360 576 567.076168 $28353.7400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 50 50 440.142852 $11003.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 646 765 6938.153922 $346908.1800 $50.0000
INTR -T1013 INTERPRETER 1 1 1.285714 $64.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 696 1701 8177.380022 $81773.8400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 76 83 541.754289 $38702.9500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 23.571429 $1348.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 71 82 601.714288 $42986.4900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 15 16 147.857142 $8451.5200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 123 861.214288 $61525.2300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 10.000000 $572.0000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 49.419048 $685.9400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 22 28 656.823013 $328.4100 $0.5000
TRAV -TRAVS Travel by mile 24 37 352.406351 $156.8200 $0.4500
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Subtotal (Total Children Is Unduplicated) 835 3476 19369.120748 $622938.3500 $32.1600
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Total 3833 19626.438758 $636190.8300 $32.4100
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Number of Children (Unduplicated) With at Least One Authorization 861