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 1232 FSPSA's found of which 7 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 12 14 2.368797 $114.8800 $48.5000
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 -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.333333 $25.0000 $74.9900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 0.060575 $4.5500 $75.1500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 0.041093 $2.2900 $55.6300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.005479 $0.4100 $75.2900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.145205 $7.4100 $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 1 1 0.322222 $16.4500 $51.0500
SCREEN-T1023 SCREENING 4 4 0.871538 $43.5800 $50.0000
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Subtotal (Total Children Is Unduplicated) 67 90 32.246319 $1717.5500 $53.2600
EI Services, Class # 03
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 76 159 258.785034 $12939.2700 $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 5 5 147.999999 $3700.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 16 17 72.199999 $3610.0100 $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 5 5 38.571429 $2755.5400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 10.285715 $734.8100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 12 60.214286 $4301.7200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 60 83 284.961966 $142.4800 $0.5000
TRAV -TRAVS Travel by mile 267 483 47966.097321 $21344.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 334 1142 50097.605292 $62857.0100 $1.2500
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Total 1232 50129.851611 $64574.5600 $1.2900
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Number of Children (Unduplicated) With at Least One Authorization 338