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 12719 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 29 29 19.050001 $704.8500 $37.0000
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Subtotal (Total Children Is Unduplicated) 52 56 46.994049 $710.1400 $15.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 75 84 33.661590 $1632.6100 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 21 21 8.355554 $160.4200 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.222223 $12.7400 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.955556 $8.3600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.955556 $20.8700 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.127778 $73.4600 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.955556 $21.8800 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.284931 $7.2700 $25.5300
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 3 0.316895 $39.6000 $124.9600
EVAL -96111 DEVELOPMENTAL EVALUATION 22 33 1.658134 $82.9200 $50.0100
EXIT -EXIT EXIT ASSESSMENT 304 350 485.875545 $24293.7600 $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 3.244444 $243.3300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 0.644447 $48.3500 $75.0300
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 3 3 3.672222 $275.4200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 2.411114 $133.8300 $55.5100
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 27 27 7.590575 $569.3200 $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 8 9 2.323284 $174.2600 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 0.620777 $31.6900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 6.269047 $320.0300 $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 5 5 5.861904 $299.2500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 19.601676 $1000.6800 $51.0500
SCREEN-T1023 SCREENING 21 22 14.123060 $706.1600 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.355556 $18.1500 $51.0600
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.650000 $33.1800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 31 12.172862 $621.4200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.749999 $38.2800 $51.0400
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.024658 $1.2400 $50.0900
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Subtotal (Total Children Is Unduplicated) 558 694 633.571259 $32048.7600 $50.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 23 30.090913 $150456.0000 $5000.0500
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 5 1.438889 $71.9500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 72 73 30.954188 $1547.7400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.277778 $66.4500 $239.2200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 718 875 393.828024 $19691.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 30 36 26.456812 $661.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1763 3023 4049.403371 $202470.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 60 99 164.458686 $4111.4700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 117 125 134.619626 $6730.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 80 91.298337 $4564.9200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 247 257 194.844259 $9742.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.133333 $153.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 416.000000 $10400.0000 $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 12 12 58.754763 $2937.7400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 181 204 1066.465865 $53323.3000 $50.0000
INTR -T1013 INTERPRETER 91 122 353.085167 $17654.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2993 4633 20401.826219 $204018.3700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 70 75 504.258725 $36024.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 40.557143 $2319.8700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 63 66 361.230952 $25806.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 8 57.285714 $3274.4600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 1.123287 $73.0100 $65.0000
SENS -V5060 BEHIND EAR HEARING AID
2 2 0.232877 $55.2300 $237.1400
SENS -V5264 EARMOLD 2 3 1.366666 $24.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 161 169 963.534124 $68834.8900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.000000 $228.8000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 129.357143 $1795.4800 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 2 2 1.077778 $0.5400 $0.5000
TRAV -TRAVS Travel by mile 1135 2034 95547.635398 $42518.7100 $0.4500
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Subtotal (Total Children Is Unduplicated) 4574 11969 125039.881751 $869972.4800 $6.9600
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Total 12719 125720.447059 $902731.3800 $7.1800
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Number of Children (Unduplicated) With at Least One Authorization 4737