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 11438 FSPSA's found of which 964 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 52 52 183.172779 $6777.3900 $37.0000
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Subtotal (Total Children Is Unduplicated) 62 65 228.346589 $6888.3900 $30.1700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 29 75.543148 $3663.8400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.555556 $26.1600 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 12 12 94.750003 $1414.6200 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 93.033335 $1786.2400 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 94.750003 $987.3000 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 91.000000 $1997.4500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 14 95.384326 $834.6200 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 91.205556 $735.1200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 94.878770 $2072.1600 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 91.000000 $2629.9000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 92.788890 $6044.2800 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 3.878770 $88.8300 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 91.505555 $2336.1400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.136986 $6.4100 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.909589 $108.8000 $119.6100
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 0.145205 $18.1500 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 11 17 23.178082 $1158.9100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 235 262 361.210029 $18060.4900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.010959 $0.8300 $75.2800
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 2 2 2.044444 $153.3300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.466667 $35.0000 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 6 2.122145 $159.1600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 1.041248 $57.7900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 12 2.465901 $184.9600 $75.0100
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.010958 $0.8300 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 5.554791 $308.3000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 5 3.508219 $263.1200 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 10.517329 $536.9100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 16 3.522525 $179.8100 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 43 45 25.553990 $3833.1500 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 3.171775 $161.9200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 70.093302 $3578.2600 $51.0500
SCREEN-T1023 SCREENING 6 6 3.394444 $169.7200 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 40 42 15.280085 $780.0600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.087671 $4.4800 $51.0700
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Subtotal (Total Children Is Unduplicated) 428 586 1544.989068 $54393.1400 $35.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 1.602664 $8013.5000 $5000.1100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.666667 $83.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 7 10.096346 $504.8100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 541 621 224.488908 $11224.5200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 0.190278 $4.7600 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 786 1277 1661.933991 $83096.7400 $50.0000
CONIP -CONIP CONSULT, PHONE 24 45 59.308333 $1482.7100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.444444 $32.5800 $73.3100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 39.642858 $991.0700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 18.933333 $946.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 254 267 1431.161359 $71558.0700 $50.0000
INTR -T1013 INTERPRETER 116 141 1131.065349 $56553.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2873 4368 17356.198502 $173561.9400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 93 97 624.189283 $44592.1000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 35.885714 $2052.6700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 108 118 624.207145 $44593.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 21.285714 $1216.6900 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.416438 $98.7600 $237.1600
SENS -V5264 EARMOLD 3 3 92.133333 $1658.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 216 225 1257.889281 $89863.6000 $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 7 7 112.285715 $1558.5300 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1440 2205 10904.872034 $5452.4300 $0.5000
TRAV -TRAVS Travel by mile 909 1372 35129.955857 $15632.8300 $0.4500
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Subtotal (Total Children Is Unduplicated) 4880 10787 70743.282117 $614969.4400 $8.6900
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Total 11438 72516.617774 $676250.9700 $9.3300
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Number of Children (Unduplicated) With at Least One Authorization 5022