Summary Report for FSPSAs Ending During the Report Period Center: 53
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 1255 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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.142857 $5.2900 $37.0100
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 9.113096 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 0.714285 $26.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 7 9.970238 $31.7200 $3.1800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 118.011111 $5723.5400 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.450000 $21.0600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.900000 $107.6400 $119.6000
EXIT -EXIT EXIT ASSESSMENT 3 3 25.377778 $1268.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 8 3.494444 $262.0800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 23 33 163.500003 $12262.5200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 18 9.499998 $712.4900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 25 34 14.722225 $817.1000 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 3 3.116667 $233.7500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 36 57.155173 $3172.1200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 14.505479 $1087.9100 $75.0000
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Subtotal (Total Children Is Unduplicated) 89 149 410.732878 $25669.1000 $62.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 0.877778 $4389.0000 $5000.1300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 19 19 12.959523 $647.9800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.327778 $23.4700 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 37 106.900000 $5345.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 0.505556 $12.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 103 127 162.746033 $8137.3100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 4.694444 $117.3600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 1.800000 $131.9800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 47.566667 $1189.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 303 349 2055.354766 $102767.7400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 292 422 1743.055691 $17430.5600 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.450000 $29.2500 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.900000 $213.4100 $237.1200
SENS -V5264 EARMOLD 1 1 1.800000 $32.4000 $18.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 72 118 670.134125 $335.0700 $0.5000
TRAV -TRAVS Travel by mile 2 2 1525.719842 $678.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 353 1099 6335.792203 $141481.2600 $22.3300
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Total 1255 6756.495319 $167182.0700 $24.7400
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Number of Children (Unduplicated) With at Least One Authorization 365