Summary Report for FSPSAs Initiated During the Report Period Statewide
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 25251 FSPSA's found of which 1664 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 21 30 123.632542 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 113 118 626.227384 $23170.4000 $37.0000
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Subtotal (Total Children Is Unduplicated) 135 151 752.859926 $23281.4000 $30.9200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 76 95 108.554717 $5264.9000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 2.794444 $131.5900 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 51 51 115.194443 $1719.8500 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 45 46 109.811111 $2108.3700 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 51 52 115.705554 $1205.6500 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 91.000000 $1997.4500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 51 52 115.317655 $1009.0300 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 91.205556 $735.1200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 52 115.323210 $2518.6600 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 91.000000 $2629.9000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 29 29 104.472221 $6805.3100 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 49 49 23.300988 $533.5900 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 91.935388 $2347.1100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.648097 $30.3300 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 2.442922 $292.1800 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 17 24 30.158600 $1507.9300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 313 342 432.156605 $21607.8300 $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 5 5 3.116666 $233.7500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 5.066667 $380.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 10 3.705478 $277.9100 $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 11 13 2.717956 $203.8700 $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 5 6 3.760274 $282.0200 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 12.116416 $618.5400 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 39 23.580297 $1203.7600 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 57 62 57.185822 $8577.9200 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 17 18 7.874949 $402.0100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 77.056542 $3933.7200 $51.0500
SCREEN-T1023 SCREENING 17 18 10.181888 $509.1000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.200000 $10.2100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.590563 $30.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 69 73 78.811416 $4023.3400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 27.168624 $1386.9600 $51.0500
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Subtotal (Total Children Is Unduplicated) 703 1128 1973.633266 $75530.5000 $38.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 15 4.723973 $23620.5000 $5000.1300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 6.506349 $325.3200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 63 66 81.896019 $4094.8000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 10.444444 $747.9200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.065753 $15.7400 $239.3700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 724 882 468.206424 $23410.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 18 13.792660 $344.8200 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 2154 4345 7695.953228 $384798.1900 $50.0000
CONIP -CONIP CONSULT, PHONE 67 132 213.333731 $5333.3500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 3.511111 $257.4300 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 9.571429 $239.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 275.804779 $6895.1300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 9 52.499999 $2625.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 505 561 4150.004356 $207500.4700 $50.0000
INTR -T1013 INTERPRETER 176 222 2307.251910 $115362.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 5828 10186 56221.591670 $562216.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 154 182 1421.072219 $101521.4600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 14 16 91.885715 $5255.8700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 181 220 1415.605565 $101130.8700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 13 14 121.642856 $6953.1100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 10 6.415220 $416.9900 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.416438 $98.7600 $237.1600
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.131507 $31.1800 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.128767 $61.0800 $474.3600
SENS -V5264 EARMOLD 6 7 95.777777 $1724.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 391 457 3294.018025 $235324.8200 $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 18 18 185.503174 $2574.7800 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 2475 3802 27286.285877 $13643.1200 $0.5000
TRAV -TRAVS Travel by mile 1498 2776 134552.268291 $59875.7700 $0.4500
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Subtotal (Total Children Is Unduplicated) 8874 23972 239989.737837 $1866595.2900 $7.7800
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Total 25251 242716.231029 $1965407.1800 $8.1000
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Number of Children (Unduplicated) With at Least One Authorization 9056