Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 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 6695 FSPSA's found of which 129 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 15 23 182.591669 $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) 17 31 211.448811 $1067.7200 $5.0500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 6 281.611111 $13658.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.111111 $52.3200 $47.0900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.277778 $13.3100 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 33 35 23.595238 $517.9200 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.950000 $192.1600 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.022222 $39.2200 $38.3700
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 6 4.627779 $216.5900 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 4.694444 $561.4500 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 4 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 42.707718 $2135.3900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 7 13.616668 $1021.2600 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 34 44.588890 $3344.1800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 80 126 751.905027 $56392.9100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 9.566667 $717.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 59 111 236.755328 $17756.6600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 114 157 241.351060 $13395.0200 $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 5 8 6.294366 $472.0700 $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 103 106 185.910651 $10318.0400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 60 67 92.731058 $6954.8400 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 11 13 6.293987 $944.0900 $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) 361 720 1979.116659 $130142.4000 $65.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 19 11.757533 $58787.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.238888 $111.9400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 98 103 94.950965 $4747.5400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 1.422222 $101.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 2.087878 $499.4300 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 112 157 722.059557 $36102.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 8 4.477779 $111.9500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 345 641 1442.298422 $72114.9700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 41 56 123.922220 $3098.0500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 18 57.949205 $4248.8400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 40 357.523810 $8938.1000 $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 899 1936 19485.113346 $974255.8700 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 811 1987 16735.998394 $167360.0100 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.672223 $108.7000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.344444 $793.0200 $237.1200
SENS -V5264 EARMOLD 5 7 8.200000 $147.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 7.142857 $510.2900 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 384 909 5899.954533 $2949.9800 $0.5000
TRAV -TRAVS Travel by mile 11 12 4687.460938 $2085.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 968 5944 49715.764103 $1340383.9700 $26.9600
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Total 6695 51906.329573 $1471594.0900 $28.3500
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Number of Children (Unduplicated) With at Least One Authorization 977