Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 1415 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.142857 $5.2900 $37.0100
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 6 13.565477 $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) 5 9 14.422619 $31.7200 $2.2000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 3 1.433333 $69.5200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.316667 $14.9100 $47.0900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.266667 $2.7800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 0.672222 $14.7500 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.944444 $61.5200 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.072223 $50.1800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.677778 $81.0600 $119.6000
EXIT -EXIT EXIT ASSESSMENT 4 4 25.911111 $1295.5600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 2.883333 $216.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 3.688889 $276.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 18 29 14.557082 $1091.8100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.400000 $180.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 21 21 16.638890 $1247.9300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 39 52 34.562638 $1918.2500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 36 56.321839 $3125.8700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 14.788812 $1109.1600 $75.0000
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Subtotal (Total Children Is Unduplicated) 98 178 177.135928 $10756.2100 $60.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.744444 $3722.0000 $4999.7000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.505556 $25.2800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 45 45 15.472059 $773.6100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.011111 $0.7900 $71.5400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 41 43 109.588888 $5479.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 0.505556 $12.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 146 185 229.034921 $11451.7500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 14 18 19.088888 $477.2200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 1.409524 $103.3500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 44.880954 $1122.0300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 332 362 1829.129337 $91456.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 363 543 2012.825508 $20128.2800 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.200000 $13.0000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.400000 $94.8500 $237.1200
SENS -V5264 EARMOLD 2 2 1.077778 $19.4000 $18.0000
TRAV -TRAVS Travel by mile 1 1 0.005556 $0.0000 $0.4500
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Subtotal (Total Children Is Unduplicated) 384 1228 4264.880080 $134880.1900 $31.6300
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Total 1415 4456.438627 $145668.1200 $32.6900
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Number of Children (Unduplicated) With at Least One Authorization 390