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
Eligibility Filter: Program Patients
With the filters selected there were 1848 FSPSA's found of which 9 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 17 19 4.513241 $218.8900 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 4 5 0.871234 $43.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 53 53 28.187880 $1409.3900 $50.0000
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 3 3 0.010959 $0.6000 $55.1900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 36 36 0.246104 $18.5000 $75.1800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 0.035615 $2.6800 $75.1800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 0.247928 $13.8000 $55.6600
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 6 0.030135 $2.2700 $75.1600
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 34.430919 $1757.7000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.106849 $5.4500 $51.0300
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 14 15 1.887671 $283.1600 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.322222 $16.4500 $51.0500
SCREEN-T1023 SCREENING 7 8 1.628844 $81.4500 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 137 205 72.858413 $3879.2900 $53.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.433334 $17167.0000 $5000.1000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 63 72 13.308040 $665.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.079452 $1.9900 $24.9800
CONIF -CONIF CONSULT, ITDS FACE TO FACE 103 212 339.051710 $16952.6500 $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 9 9 184.285714 $4607.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 45 222.733332 $11136.6700 $50.0000
INTR -T1013 INTERPRETER 18 23 4.394065 $219.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 268 412 1887.106571 $18871.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 15 134.214287 $9588.2600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 25.428572 $1816.6100 $71.4400
SENS -V5264 EARMOLD 1 1 0.263014 $4.7300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 47 55 417.755190 $29844.4300 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 87 131 410.722000 $205.3600 $0.5000
TRAV -TRAVS Travel by mile 359 653 70096.247409 $31192.8400 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 454 1643 73743.672690 $142411.2800 $1.9300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1848 73816.531103 $146290.5600 $1.9800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 459