Summary Report for FSPSAs Ending During the Report Period Center: 04
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 640 FSPSA's found
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.059525 $2.2000 $36.9800
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Subtotal (Total Children Is Unduplicated) 1 1 0.059525 $2.2000 $36.9800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.922222 $44.7300 $48.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.394444 $20.1300 $51.0400
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.615080 $286.6600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 4.670635 $238.4400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.033333 $1.7000 $51.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.850000 $43.3900 $51.0500
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Subtotal (Total Children Is Unduplicated) 12 15 12.485714 $635.0500 $50.8600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 41 4.327781 $216.4100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 5 2.111111 $105.5600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.714286 $92.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 28 203.750000 $10187.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 475 538 3330.875427 $33308.7500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 30.857143 $2204.4300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 15.000000 $1071.6000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 20.571428 $1469.6300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.571429 $7.9300 $13.8800
TRAV -TRAVS Travel by mile 1 1 3.857143 $1.7200 $0.4400
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Subtotal (Total Children Is Unduplicated) 491 624 3615.635748 $48666.3700 $13.4600
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Total 640 3628.180987 $49303.6200 $13.5900
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Number of Children (Unduplicated) With at Least One Authorization 496