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 2490 FSPSA's found of which 8 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 2.095555 $77.5300 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 2.095555 $77.5300 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.438889 $28.5900 $65.1400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 2.338889 $119.4000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 21 10.765077 $549.5500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 3.962251 $202.2700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 2.449998 $125.0600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 39 43 52.675451 $2689.0900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 22.203175 $1133.4700 $51.0500
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Subtotal (Total Children Is Unduplicated) 68 93 94.833730 $4847.4300 $51.1200
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 360 576 567.076168 $28353.7400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 22 217.504765 $10875.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 686 1674 8002.603038 $80026.0700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 13 118.321428 $8452.8800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.571429 $261.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 7 7 66.285714 $4735.4500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 60.142856 $3437.7700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 24 174.321429 $12453.5200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 28.128571 $390.4300 $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) 730 2392 10251.613333 $149667.9300 $14.6000
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Total 2490 10348.542618 $154592.8900 $14.9400
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Number of Children (Unduplicated) With at Least One Authorization 754