Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 09
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 183 FSPSA's found of which 11 had no frequency modifier field, FORCE FREQ MODIFIER to 0
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1 3 3.033333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 3 3.033333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.955556 $18.3500 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.955556 $9.9600 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.955556 $8.3600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.955556 $20.8700 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.955556 $62.2500 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.955556 $21.8800 $22.9000
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Subtotal (Total Children Is Unduplicated) 1 6 5.733336 $141.6700 $24.7100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.955556 $47.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 45 1.659049 $82.9600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.006850 $0.1700 $24.8200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 9 2.459522 $122.9700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.101370 $5.0700 $50.0100
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 15 85.361905 $4268.0900 $50.0000
INTR -T1013 INTERPRETER 9 9 182.714286 $9135.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 10 39.614286 $2830.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 9 56.928572 $4066.9700 $71.4400
SENS -V5264 EARMOLD 1 1 0.900000 $16.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 35 219.480956 $15679.7200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 29 36 139.147618 $69.5700 $0.5000
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Subtotal (Total Children Is Unduplicated) 88 174 729.335526 $36325.5500 $49.8100
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Total 183 738.102195 $36467.2200 $49.4100
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Number of Children (Unduplicated) With at Least One Authorization 89