Summary Report for FSPSAs Ending During the Report Period Statewide
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 25306 FSPSA's found of which 729 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 4 2.611111 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 12 15 51.962303 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 123 130 103.966962 $3846.7900 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 137 150 158.683233 $3852.0800 $24.2800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 54 60 136.778613 $6633.7500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 14 14 4.568265 $215.1200 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 127 128 33.077776 $493.8500 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 140 151 57.288887 $1099.9400 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 127 128 32.241474 $335.9500 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 2.294977 $50.3700 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 133 133 32.909434 $287.9600 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.200000 $1.6100 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 132 133 32.709434 $714.3700 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 72 73 18.740561 $1220.7500 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 128 128 32.027852 $733.4300 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.268493 $6.8500 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 5.139650 $240.5300 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 21 22 7.013394 $838.7800 $119.6000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 2 0.183562 $22.9400 $124.9600
EVAL -96111 DEVELOPMENTAL EVALUATION 17 28 1.407907 $70.4200 $50.0100
EXIT -EXIT EXIT ASSESSMENT 280 315 482.890930 $24144.5300 $50.0000
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 0.677778 $37.6200 $55.5000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 37 40 18.571691 $1392.9100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 42 52 177.609894 $13320.7700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 14 14 0.481388 $36.1100 $75.0200
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 32 42 28.425808 $2131.9200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 58 67 36.437322 $2022.2900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 517 517 214.197112 $16065.2600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 146 147 106.053587 $7954.1400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 120 120 22.038318 $1652.9900 $75.0100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 427 430 289.028412 $16041.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 238 255 142.885919 $10716.6100 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.714286 $35.7200 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 6 23.284126 $1164.2100 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 39 40 26.752370 $1365.7000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 155 160 89.158045 $4551.5300 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 13 16 5.616831 $842.5200 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 53 56 14.396279 $734.9200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 115 122 142.620666 $7280.7700 $51.0500
SCREEN-T1023 SCREENING 45 45 22.298174 $1114.9100 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.405555 $6.3300 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 0.457915 $23.3800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.036073 $1.8400 $50.9500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 237 248 269.755912 $13771.0400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 7 7 7.703175 $393.2500 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.109589 $5.4800 $50.0100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1983 3729 2519.457434 $139774.5700 $55.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 65 73 14.080911 $70405.5000 $5000.0700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 2.122222 $106.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 41 41 53.168580 $2658.4300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 1.472222 $105.4200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.372907 $89.2000 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 733 865 382.628814 $19131.6100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 63 74 19.653869 $491.3400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1499 2619 3542.194974 $177109.9000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 32 54 59.521350 $1488.0300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 61 72.096826 $3604.8400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 61 77.720558 $3886.0300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 125 130 135.834128 $6791.7200 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 1.800000 $131.9800 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 71.428571 $1785.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 196 225 2287.247658 $57181.1800 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 9 9 27.134921 $1356.7500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4463 5071 29421.331578 $1471066.1900 $50.0000
INTR -T1013 INTERPRETER 122 149 657.032409 $32851.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3274 5221 19956.697146 $199566.8800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 622 684 3677.482229 $262719.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 67 72 338.783339 $19378.3800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 768 866 4442.798321 $317393.3300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 55 58 247.120638 $14125.4100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 1.874047 $121.8100 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.541667 $64.2200 $118.5700
SENS -V5050 IN EAR MONAURAL HEARING AID 11 11 2.435921 $577.6000 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.095890 $45.4800 $474.2900
SENS -V5264 EARMOLD 34 37 29.741553 $535.3500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1191 1349 7375.098291 $526876.9800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 10.857143 $621.0300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 28 28 162.503175 $2255.5400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1227 1801 8067.187479 $4033.5900 $0.5000
TRAV -TRAVS Travel by mile 1139 1843 59426.786534 $26444.9300 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6636 21427 140566.845871 $3225001.4100 $22.9400
-------------------------------------------------------------------------------------------------------------------------------------
Total 25306 143244.986538 $3368628.0500 $23.5200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 7302