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 13874 FSPSA's found of which 647 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 2 3 2.233333 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 12 15 51.962303 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 70 75 65.950452 $2440.1700 $37.0000
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Subtotal (Total Children Is Unduplicated) 84 94 120.288945 $2445.4600 $20.3300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 50 56 135.761490 $6584.4200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 2.944444 $138.6500 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 38 38 10.233333 $152.7800 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 42 42 12.311109 $236.3700 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 38 39 10.272222 $107.0400 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 37 37 9.794444 $85.7000 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 38 38 10.233333 $223.5000 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 22 22 5.694444 $370.9300 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 36 36 9.905556 $226.8400 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.227397 $5.8100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.388889 $18.2000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.255556 $150.1700 $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 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 -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.415525 $31.1600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.850000 $63.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 1.500687 $83.3000 $55.5100
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 7.445370 $558.4300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 7.307630 $548.0800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.010958 $0.8300 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 9.085384 $504.2400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 2.032874 $152.4800 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.714286 $35.7200 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 13.416634 $684.9200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 27 26.372016 $1346.3000 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 12 15 5.616831 $842.5200 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 13 3.965079 $202.4200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 12 7.209524 $368.0500 $51.0500
SCREEN-T1023 SCREENING 14 14 10.249314 $512.4600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.172222 $2.6900 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.385693 $19.6900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.033333 $1.7000 $51.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 44 45 16.617189 $848.3100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 5 5 7.486508 $382.1900 $51.0500
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Subtotal (Total Children Is Unduplicated) 567 900 816.736121 $39890.1400 $48.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 15 2.335771 $11679.5000 $5000.2800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.111111 $55.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 31 31 45.684410 $2284.2300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.861111 $61.6600 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 647 766 367.070224 $18353.7100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 13 15 4.509590 $112.7400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1426 2476 3351.454217 $167572.8600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 28 49 58.401942 $1460.0400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 58 65.288889 $3264.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 55 72.918178 $3645.9100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 119 124 135.374605 $6768.7400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.733333 $127.0900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 167.857142 $4196.4300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 7 16.300000 $815.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 278 306 1484.724612 $74236.2200 $50.0000
INTR -T1013 INTERPRETER 122 149 657.032409 $32851.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3258 5169 19892.841591 $198928.3200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 84 90 466.267065 $33310.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 28.950000 $1655.9500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 83 89 424.376192 $30317.4300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 32.250000 $1843.4100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 1.424047 $92.5600 $65.0000
SENS -V5264 EARMOLD 4 5 4.422222 $79.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 201 212 1065.495089 $76118.9600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 38.287302 $531.4300 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 898 1380 5892.099398 $2946.0500 $0.5000
TRAV -TRAVS Travel by mile 1139 1842 59422.357963 $26442.9600 $0.4500
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Subtotal (Total Children Is Unduplicated) 5082 12880 93701.428413 $699752.5400 $7.4700
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Total 13874 94638.453479 $742088.1400 $7.8400
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Number of Children (Unduplicated) With at Least One Authorization 5262