Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1871 FSPSA's found of which 14 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 17 3.347564 $162.3500 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 2.294977 $50.3700 $21.9500
EVAL -96111 DEVELOPMENTAL EVALUATION 4 5 0.871234 $43.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 40 40 26.246021 $1312.3000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 0.027395 $2.0600 $75.2900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.333333 $25.0000 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 0.043985 $2.4500 $55.6400
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 113 113 0.728503 $54.7600 $75.1600
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 0.065748 $4.9500 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 134 134 0.818524 $45.5300 $55.6300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 0.071228 $5.3600 $75.1800
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 0.892846 $45.5800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 0.947944 $48.3900 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 7 7 0.980822 $147.1200 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 0.882725 $45.0600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 2.822223 $144.0800 $51.0500
SCREEN-T1023 SCREENING 5 5 1.371538 $68.5800 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 0.350684 $17.9000 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.109589 $5.4800 $50.0100
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Subtotal (Total Children Is Unduplicated) 221 396 43.212362 $2231.3000 $51.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 19 3.648020 $18240.0000 $4999.9700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 45 51 11.937888 $596.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.002740 $0.0700 $24.6400
CONIF -CONIF CONSULT, ITDS FACE TO FACE 77 160 258.851701 $12942.6100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 3.800000 $95.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.050000 $2.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.800000 $40.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 14 448.142856 $11203.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 151 160 970.619050 $48530.9200 $50.0000
INTR -T1013 INTERPRETER 16 21 4.371919 $218.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 196 298 1237.526996 $12375.2500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 47 49 377.571428 $26973.7100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 61 66 478.392859 $34176.3600 $71.4400
SENS -V5264 EARMOLD 1 1 0.723288 $13.0200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 62 406.428572 $29035.2600 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 62 85 287.628633 $143.8100 $0.5000
TRAV -TRAVS Travel by mile 267 483 47966.097321 $21344.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 357 1474 52456.593271 $215932.4400 $4.1200
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Total 1870 52499.805633 $218163.7400 $4.1600
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Number of Children (Unduplicated) With at Least One Authorization 367