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 781 FSPSA's found of which 13 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
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Subtotal (Total Children Is Unduplicated) 4 5 9.255953 $5.2900 $0.5700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 118.011111 $5723.5400 $48.5000
EXIT -EXIT EXIT ASSESSMENT 3 3 25.377778 $1268.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.544444 $40.8300 $74.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 1.122226 $84.2000 $75.0200
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.422222 $31.6700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 0.950003 $52.7400 $55.5200
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Subtotal (Total Children Is Unduplicated) 19 28 146.427784 $7201.8600 $49.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.111111 $555.5000 $4999.5000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 17 11.026190 $551.3100 $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 1 1 1.733333 $127.0900 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 16 27.704762 $1385.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 292 420 1741.698548 $17416.9900 $10.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 71 116 666.972221 $333.4900 $0.5000
TRAV -TRAVS Travel by mile 2 2 1525.719842 $678.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 344 748 4250.139818 $34684.3400 $8.1600
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Total 781 4405.823555 $41891.4800 $9.5100
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Number of Children (Unduplicated) With at Least One Authorization 350