Summary Report for FSPSAs Initiated During the Report Period Statewide
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 23000 FSPSA's found of which 1 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 12 13 6.150000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 13 21.651191 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 69 70 37.113492 $1373.2000 $37.0000
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Subtotal (Total Children Is Unduplicated) 90 97 65.057540 $1378.4900 $21.1900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 83 92 45.974680 $2229.8000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 1.072222 $50.4900 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 0.727778 $10.8700 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 91 92 30.794441 $591.2500 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.712786 $17.8500 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 1.505099 $33.0300 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 1.952968 $17.0900 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 1.952968 $42.6500 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 9 9 4.055555 $264.1800 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 1.952968 $44.7200 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.284931 $7.2700 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 9.284585 $434.5200 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 19 19 6.305478 $754.1300 $119.6000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 3 0.316895 $39.6000 $124.9600
EVAL -96111 DEVELOPMENTAL EVALUATION 23 34 1.948545 $97.4400 $50.0100
EXIT -EXIT EXIT ASSESSMENT 304 350 485.875545 $24293.7600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 2.883333 $216.2500 $75.0000
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 39 41 26.034933 $1952.6600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 36 47 28.625877 $2146.9800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 18 18 3.064645 $229.8600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 45 48 43.052511 $3228.9500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 74 87 58.440293 $3243.4700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 520 521 215.175194 $16138.6200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 146 146 103.238290 $7742.9900 $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 430 433 361.787315 $20079.3400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 242 262 253.814457 $19036.2500 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 8 32.904760 $1645.2400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 28 28 11.705077 $597.5500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 158 162 92.752335 $4735.0100 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 0.389041 $58.3500 $149.9800
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 40 40 15.249882 $778.5100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 164 171 139.749611 $7134.2400 $51.0500
SCREEN-T1023 SCREENING 60 61 28.482421 $1424.1300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 0.627474 $32.0300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 0.763851 $38.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 254 259 237.926220 $12146.1400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 27 27 6.146738 $313.7900 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.169863 $8.5000 $50.0100
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Subtotal (Total Children Is Unduplicated) 1983 3150 2281.417661 $133547.0700 $58.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 90 98 137.344873 $686727.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 7 8 3.605556 $180.2800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 83 84 40.243915 $2012.2300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 3.644521 $260.9800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 3.053653 $730.4500 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 813 985 411.625415 $20581.4200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 81 96 29.778032 $744.4400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1835 3164 4224.494562 $211224.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 67 108 172.681268 $4317.0300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 130 139 142.042641 $7102.1300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 84 97 100.809448 $5040.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 264 274 206.217274 $10310.8600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.847619 $196.1900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 1.409524 $103.3500 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.714286 $42.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 196 208 2547.928555 $63698.2400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 8.285714 $414.2900 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 15 15 69.424713 $3471.2400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4482 4903 28448.398062 $1422420.7600 $50.0000
INTR -T1013 INTERPRETER 91 122 353.085167 $17654.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2995 4637 20422.469076 $204224.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 583 622 3430.235173 $245056.1800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 87 95 509.833331 $29162.4900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 636 691 3671.655866 $262303.2900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 50 54 238.264496 $13619.2000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 1.123287 $73.0100 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 9 9 1.966209 $466.2300 $237.1200
SENS -V5060 BEHIND EAR HEARING AID
3 3 0.449315 $106.5400 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.341400 $161.9100 $474.2400
SENS -V5264 EARMOLD 29 30 22.126329 $398.2700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1101 1186 6833.570987 $488190.6100 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 14.571429 $833.4800 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 43 44 340.361904 $4724.2200 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 2 2 1.077778 $0.5400 $0.5000
TRAV -TRAVS Travel by mile 1137 2041 95954.063970 $42699.5700 $0.4500
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Subtotal (Total Children Is Unduplicated) 6306 19753 168355.745348 $3749254.1400 $22.2700
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Total 23000 170702.220549 $3884179.7000 $22.7500
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Number of Children (Unduplicated) With at Least One Authorization 6676