Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 07-01-15 and 06-30-16 Date of Report: 08-06-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 6443 FSPSA's found of which 313 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 2 4 3.142857 $116.2900 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 17 137.387701 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 25.714285 $951.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 13 25 166.244843 $1067.7200 $6.4200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 5 280.611111 $13609.6400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 7 7 5.361111 $117.6800 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.994444 $64.7800 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.022222 $39.2200 $38.3700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 4 1.816667 $85.0200 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 4 2.783333 $332.8800 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 5 10.388889 $519.4500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 42.707718 $2135.3900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 7.700001 $577.5100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 32 42.677776 $3200.8200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 77 121 765.937304 $57445.3200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.133334 $310.0100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 63 151 245.552506 $18416.4000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 72 93 156.040479 $8660.2600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 0.027778 $2.0900 $75.0600
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 12 11.872144 $890.4000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 4.011111 $300.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 102 105 184.110651 $10218.1400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 61 68 91.939278 $6895.4600 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 17 20 9.779223 $1466.8700 $150.0000
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 12.466667 $636.4300 $51.0500
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Subtotal (Total Children Is Unduplicated) 341 659 1881.933747 $125924.5700 $66.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 14 73.190867 $365954.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 50 51 56.423133 $2821.1500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.216666 $87.1200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.501370 $119.9300 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 107 147 454.126224 $22706.3200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 3.622223 $90.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 227 404 981.326190 $49066.3100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 22 30 81.966663 $2049.1600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 10 26.520635 $1944.4900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 27 37 297.661908 $7441.5500 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 31 31 58.188889 $2909.4500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 784 1935 18400.545029 $920027.6000 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 607 1287 11419.119074 $114191.2000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.966667 $62.8400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.933333 $458.4200 $237.1200
SENS -V5264 EARMOLD 3 6 4.877778 $87.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 15.142857 $1081.8100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 579 1776 10385.238100 $5192.6200 $0.5000
TRAV -TRAVS Travel by mile 11 15 4706.813319 $2094.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 883 5759 46977.380925 $1498787.3300 $31.9000
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Total 6443 49025.559515 $1625779.6200 $33.1600
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Number of Children (Unduplicated) With at Least One Authorization 902