Summary Report for FSPSAs Ending During the Report Period Statewide
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 21179 FSPSA's found of which 1121 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 3 3.000000 $111.0000 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 9 10 42.173810 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 101 101 751.726063 $27813.8700 $37.0000
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Subtotal (Total Children Is Unduplicated) 109 114 796.899873 $27924.8700 $35.0400
Screening, Eval, and Assessment, Class # 02
AACIO -92597GO AAC INITIAL EVAL BY LICENSED OT 1 1 0.005479 $0.5600 $103.0300
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $205.2600 $102.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 30 75.748704 $3673.8100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.672223 $31.6600 $47.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 82 82 117.285396 $1751.0800 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 52 52 106.985395 $2054.1300 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 83 84 119.840951 $1248.7500 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 91.481584 $2008.0200 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 85 86 121.033722 $1059.0500 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 91.738889 $739.4200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 87 89 121.560357 $2654.8900 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 91.000000 $2629.9000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 40 40 103.685394 $6754.1100 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 83 83 26.689277 $611.2000 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 93.838888 $2395.7000 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 9 5.536606 $259.1100 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 19 22 12.425418 $1486.1000 $119.6000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 0.145205 $18.1500 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 12 18 23.347945 $1167.4000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 240 267 364.721140 $18236.0500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 0.977626 $73.3300 $75.0100
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 0.283333 $15.7200 $55.4900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 22 17.479904 $1311.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 19 21 51.283886 $3846.3000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 4.513699 $338.5300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 44 65.885092 $4941.3900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 29 28.847764 $1601.0600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 350 354 138.759102 $10407.3000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 138 138 73.157803 $5486.9600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 82 83 32.623269 $2446.8100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 314 319 241.278784 $13391.0500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 182 201 125.602667 $9420.3000 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 19.142858 $957.1400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 29 29 20.536038 $1048.3500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 106 108 50.612568 $2583.7900 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 47 49 31.823396 $4773.5700 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 43 43 18.934475 $966.6100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 78 79 106.854031 $5454.8900 $51.0500
SCREEN-T1023 SCREENING 28 29 12.545207 $627.2600 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 182 187 124.288010 $6344.9200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 62.087671 $3169.5800 $51.0500
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Subtotal (Total Children Is Unduplicated) 1454 2628 2797.259756 $128190.2100 $45.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 30 12.883539 $64418.0000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 13.380953 $669.0500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 11 14.829679 $741.4800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.005556 $0.4000 $72.1700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 635 743 234.391397 $11719.6000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 31 33 1.269110 $31.7200 $24.9900
CONIF -CONIF CONSULT, FACE TO FACE 854 1402 1798.981026 $89949.0700 $50.0000
CONIP -CONIP CONSULT, PHONE 34 57 61.405365 $1535.1400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.444444 $32.5800 $73.3100
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 32.000000 $800.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 145 158 1057.466931 $26436.6600 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 18.933333 $946.6700 $50.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 2 2 2.202740 $110.1400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4147 4571 26740.173876 $1337008.7000 $50.0000
INTR -T1013 INTERPRETER 118 143 1132.362174 $56618.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2892 4411 17491.543742 $174915.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 541 591 3083.530119 $220287.4700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 42 44 221.608334 $12675.9800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 719 777 3859.642888 $275732.8200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 50 50 233.175397 $13328.2900 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 9 9 1.949391 $462.2700 $237.1300
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.082192 $38.9800 $474.2900
SENS -V5264 EARMOLD 32 33 110.514612 $1989.2600 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1108 1203 6776.776153 $484132.9300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 10.142857 $580.1700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 203.500002 $2824.5800 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1838 2761 14015.935871 $7007.9500 $0.5000
TRAV -TRAVS Travel by mile 909 1379 35164.813000 $15648.3500 $0.4500
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Subtotal (Total Children Is Unduplicated) 6122 18437 112293.944681 $2800641.7700 $24.9400
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Total 21179 115888.104310 $2956756.8400 $25.5100
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Number of Children (Unduplicated) With at Least One Authorization 6676