Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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 2934 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 Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.142857 $5.2900 $37.0100
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 12 78.648810 $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) 8 15 79.505952 $31.7200 $0.4000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 4 119.433333 $5792.5200 $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 7 7 2.694446 $59.1500 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 1.450000 $94.4500 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.505556 $19.4000 $38.3700
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.522223 $71.2400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.577778 $188.7000 $119.6000
EXIT -EXIT EXIT ASSESSMENT 4 4 25.911111 $1295.5600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 3.894444 $292.0800 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 14 12.683334 $951.2600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 47 67 200.762641 $15057.2600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 3.916667 $293.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 35 43 34.177779 $2563.3400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 73 97 85.607088 $4751.2500 $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 36 37 57.438506 $3187.8400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 14.788812 $1109.1600 $75.0000
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 6.066667 $309.7100 $51.0500
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Subtotal (Total Children Is Unduplicated) 151 308 576.130386 $36288.1000 $62.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 2.633334 $13167.0000 $5000.1300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.505556 $25.2800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 80 82 38.848474 $1942.4700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.338889 $24.2700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.249315 $59.6300 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 56 64 240.149315 $12007.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 1.516667 $37.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 228 338 458.727782 $22936.4100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 27 34 47.699997 $1192.4900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 3.142857 $230.4400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 24 110.647622 $2766.1900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 591 842 5576.967441 $278848.4600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 584 1079 5530.877899 $55308.8000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.650000 $42.2500 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.300000 $308.2600 $237.1200
SENS -V5264 EARMOLD 3 3 2.877778 $51.8000 $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) 615 2611 14212.986893 $389963.1400 $27.4400
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Total 2934 14868.623231 $426282.9600 $28.6700
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Number of Children (Unduplicated) With at Least One Authorization 617